20160823094235.pdf,ME
11 I DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
�`slt I 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 !& Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
tt erect, Suite #, City Sta'hte„ Zip):
Parcel #:
Subdivision/Lot #:
Project Valuation: $ 12,400
APPLICANT:
Phone: Fax:
HAIDL9(Am2da(
—
Address (Street, City, State, Zip):
E-Mail Address:
Swa '" T
rion. com
IPIIaI"M'"Y O NER:
Phone: Fax:
Address (Street, City„ Staatc, Zilt):
E-Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip);
E-Mail Address:
CONTRACTOR:*
Phone: Fax:
l
10 —
Address (Street, City, State, Zip):
E-Maif Address:
t-d Im =5JW M
Ckaidec =si ak 1 t
WA State License #/Exp. Date,
*Contractor must have a valid City of Edmonds business license prior to r ` e
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
DETAIL THE SCOPE OF WORK: ._._
w .....e
�. ..... . tt.w? .....," ... �:. ,
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: e.., -sq. ft.
Select Basement Type: Finished 1_1 Unfinished ......
1st Floor:.. ......... �.. �sr , ft.
Garage/Carport. �e. _... __
2" d Floor: _....... m._. st:. ft.
Deck/Cvrd Porch/Patio: st . ft.
Bedrooms # „ , Full-3/4 Bath # Half -Bath #.._ .,.
Other: _ s . ft.
Fire Sprinklers: Yes No
Retainin Wall: Yes NoLD
Grading: Cut cu. yds. Fill cu.yds.
Cut/Fill in Critical Area: Yes No
I declare under penalty of perjury laws that the information I have provided on this form/application is true, correcl and
complete, and that I am the property owner or duly authorized
agent of the property owner to submit a permit application to
the City of Edmonds.
"
Owner Agen L/Other 2 (specify):
Print Name:�.� a.Unla
............... _�.._
Date:
Signature: ,�..
FORM A LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014.docx Updated: 1/17/2014