20160920112813.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
"sr I�tll 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 Q Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #.
Subdivision/Lot #: Project Valuation: $ // ,,,, ffy)�
APPLICANT:�`1i� CU��\n P onqe. U �_�� Fax:
Address (Street, City, State, Zip): i E -Mail Address:
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P'ROPE'RTY OWNER. Phone;Fax:
Address (Street, City, State, Zip): E -Mail Address:
SVJ 4v &
ENDING AGENCY, Phone: Fax:
Ad)<ss (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* Phone: Fax:
Y 1�
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 llt1si1)esg tie nse Il/1 xp. Datc.
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DETAIL TBE SCOPE OF WORK:
PROPOSED NEW S UAIW FOOTAGE FOR THIS I''ROJE ";
Basement m.. _.. sq. ft. Select Basement Lae: Finished Unfinished
I" Floor: ..... _...._.. sq. ft. Gara e/Car ort: _ ... _sq. . ft.
2i," Floor: ._...—...... _ s . ft. Deck/Cvrd Porch/Patio:
Bedrooms # Full -3/4 Bath # Half -Bath # Other: _....._ _.__. .,
Fire S rinkle:s: Yes 1,7 NoLl Retainin Wall: Yes No
Grading: Cut cu. yds. Fill cu.yds. 1 Cut/Fill in Critical Area: Yes No
I declare under penalty of perjury laws that the information 1 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.
Print Name: --- ...... -------- .. __ .... Owner ❑ Agent/Other ❑ (specify); �.....
Signature: . .---------....� Date: . � ..�. .. .......... ........ . _
FORM A L:\Building New Foldei, 2010\DONE & x-ferred to L -Building -New drive\Form A2014„doex Updated: 1/17/2014
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