20160928124129.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
POO
APPLICATION
°st lv�y 121 5`h 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, Imp):
Parcel #:
7616 7k -e �✓ -�i
w,a `f�asG
Subdivision/Lot #:
Project Valuation: $ 27 000
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APPLICANT: �oREt' / t'6 BF�4%7c.✓
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Phone: Fax:
`t -C- Mq - 7151
Address (Street, City, State, Zip):
E -Mail Address:
StF�E
tore atn k, -%y T., ig- Pl-4,
PROPERTY -OWNER:/
1 oQ6Y /LB�R Via,✓ IJi iN
Phone: Fax:
�� R.¢oA
Address (Street, City, State, Zip):
E -Mail Address:
.fif-n E"
LENDING AGENCY:
Phone: Fax:
/✓ il-
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*
/'( `ooh-c�n��r
Phone: Fax.
rlE'
.,r) 35-5-Y-
Address (Street, City, State, Zip):.
E -Mail Address:
�rtiJn.Go.t
�Cr-co rorS
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:
N -02.3178
DETAIL THE SCOPE OF WORK ..
. J
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
____-. ft.
Basement: ..,, ., -----------
Select Basement Type: Finished Unfinished _
1st Floor:.._...... .. s . ft.
Gara e/Cat ort:
2°a Floor: m�...,._. _ _ ft.
Deck/Cvrd Porch/Patio: _.._...... --S2. ft.
Bedrooms # Full -3/4 Bath # Half -Bath #
Other: mo _ _sq. ft.
Fire S rinklers: Yes No
Retainin Wall: Yes No17
Grading: Cut cu. yds. Fill cu.yds. J 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.
&1144,g- 7-3
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Owner Agent/Other ❑ (specify):—---,-.
Print Name Gra' " ,
U
Date:
Signature:
FORM A L:\Building New Folder 2010\DONE & x-ferred to L -Building -New driveTorm A2014.docx Updated: 1/17/2014
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