20160829100326.pdfr
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5"' Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 f Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street` tjitg #, Cityt te, Zip): 1 Parcel #:
I., l�J G1 T
Subdivision/Lot #: Project Valuation: $
APP ICANT: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Addres
PR ICI II"I""t" OWNER: Phone: Fax:
M
(City, Mate, ip ): f','- ` ail Address:
Address Street, S
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
CONTRACTOR:* Phone: Fax:
(Stag, f.. 1y S 1te, Zi : E-Mail Address:
Ldress
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to
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:._.�r mm
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement:f. Select Basement Type: Finished Unfinished
I" Floor: — ..... ........,e. 9,, __ _... St; ft. Gara e/Car ort: w... m, ...._ s . ft.
2"' Floor: ...... �m s . ft. Deck/Cvrd Porch/Patio: _�.u.. . ..m ft.
Bedrooms # Full-3/4 Bath # _ re, _ Half -Bath #�,.......... .. Other: . ......._ s . ft.
Fire Sprinklers: Yes EJ No Retaining Wall: Yes No
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, correct and
complete, and that I am the property owner or duly authorized agent of the property owner to submit a permit application to
p P P Y y
the City of Edmonds.
Print Name: w� ��� -���....�_ Owner ❑ Agent/Other jR (specify)7r,)v Q�
Signature:'
FORM A L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014.docx Updated: 1/17/2014