20160920082041.pdf�Nj DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
t, APPLICATION
•se t� 121 51h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 A Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
Z. 3 70� 7y rr/ /�✓e' f.✓ l^oM �n/Os l✓/!- 4'902, 0 ,q0,'/,I/
Subdivision/Lot #:
Project Valuation: $
APPLICANT: P®h�one:: t� g Fax,
1 C 61 ' 'rf P ^11 l i's r1 Al Oaf R AR,�' "T ,7 ' �i % ®/_5
Address (Street, City, State, Zip):
E -Mail Address:
5,fmr 4J
PROPERTY OWNER:
Phone: Fax:
5,¢r4E 4,s s}�Pc tc?N7'
Address (Street, City, State, Zip):
E -Mail Address:
5A,v1L ±5 1480,1C
LENDING AGENCY:
Phone: Fax:
il/ Ih
Address (Street, City, State, Zip);
E -Mail Address:
,VIA
CONTRACTOR:*
Phone:Fax:
R t_ R Crla0J:_J_ e,
011,207_.S"
Address (Street, City, State, Zip):
E -Mail Address:
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:
OR - 0 231 78
DETAIL THE SCOPE OF WORK:.w,.
2®..._.� �. . a
I
PROPOSED NEW SQUARE F()OTAGF,
q+OR "I"ms PRO ltxr:
Basement: s . ft.
Select Basement T e: Finished 71 Unfinished
?'Floor: .. w _ _s . ft.
Gara e/Car ort s . ft.
2"' Floor: _— ..... ...— _,...._..... ft.
Deck/Cvrd Porch/Patio r_ sq. ft.
Bedrooms # n Full -3/4 Bath # Half -Bath # ..en_
Other: _ . ...., — __ ------------------------- sq. ft,
Fire S rinklers: Yes No
Retainin 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
the City of Edmonds.
Print Name % e�R �` ! R ®
Owner & Agent/Other ❑ (specify):
.__ _...
.
Signature: .._ _�';� �� � �'�m^'
Date:
FORM A L:\Building New Folder 2010\DONE & x -(erred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014