20160916113953.pdfNY „
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
' APPLICATION
t,swt Att 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 0 Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PRO,111",(...� ~1IIJAZ 4S (Street,
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i Parcel #:
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Subdivision/Lot #:
Project Valuation: $ r r
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APPLICANT:�•
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Adwite.,'N (Stttet, C:'ly, title ap):
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PROPI�.I °i114` l �"�11'�IY�:II • i "�.'��
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Address (Sttettr �`iroy �t Ile, TI�1
E -Mail Address:
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LENDING AGENCY:
Phone: Fax:.
Address (Street, City, State, Zip).
E -Mail Address:
CONTRACTOR:*d m�
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Address (Street, Chy, State Zlp8 E -Mail Address
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*Contractor must have a valid City of Edmonds business license prior to 1'StatLiCenseL2 2 4 yLL„ i w„m
doingwork in the City. Contact the Cit Clerk's Office at 425.775.2525 s License lift gyp. Dater
y Y .� i�py Business
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DETAIL THE SCOPE OF WORK: 'M1 r _' t o ”' �It .i �.." .. ,. _. N..W gLL6 _SS G r
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: ----sq. ft. Select Basement T e: Finished Unfinished.71
s ft. Gara e/Car ort: —sa. ft.
1" Floor:... _. _
2 nd Floor. _..... sq. ft. Deck/Cvrd Porch/Patio _ ._ ..- sq. ft.
Bedrooms # _Full -3/4 Bath # Half -Bath # Other:.aaaaaas,_„_ti-_______------_--_- sq. ft.
Fire Sprinklers: Yes No Retainin W 11 all: Yes No
Grading: Cut cu. yds. Fill cu.yds. Cut/Fill in Critical Area: Yes LJ N071
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 ant the property owner or duly authorized agent of the property owner to submit a permit application to
the City of Edmonds.
Owner ❑ Agent/Other specify) ., .......
Print Name P........
< �wr �I n�� o...n . Date
Signature: ....__""i"�( "_... . .. �. �n..-.�.,.�_
FORMA L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014