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City of Edmonds
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5`1' Avenue N, Edmonds, WA 98020
Phone 425.771.0220 f Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Sukttllvlsicrtr/l t�l 1 ' y� t�°°.
APPLICANT:
Address (Street, City, State, Zip):
PROPERTY OWNER:
Address (Street, City, State, Zip):
LENDING AGENCY:
Address (Street, City, State, Zip):
(Street, City„ State, Zip):
Parcel #:
Project Valuation: $ C 06
Phone: Fax:
E-Mail Address:
Phone: Fax:
E-Mail Address,
Phone: Fax:
E-Mail Address:
PI oue.
E-Mail Address
WA State License #/ :xp, Date:_ s ,
*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..,_
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement
1" Floor: �....._ ....
2"" Floor: _-. �._,_.��...
Bedrooms # Full-3/4 Bath #,__.__
m
Fire )ritnkle s Yes No
Gradine. Cut- __.:t1. yds, Fill
, ft. Select Basement Type: Finished Unfinished
s „
__�..
ft, Deck/Cvrd Porch/Patio: ...... _ _.._"'o, ft.
Half -Bath # Other: _w�......m_� .m......_ �.... _. -�, m �..
sa:�. ft.
Retainin� Wall: Yes No
cu.vtls. 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 l dr io
Print Name t TMi �..w,...a .....� Owner • tYent/Offier ❑ (specify)
Date:Si nature: t. _..._ e.._.—r....�.._
FORM A L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014.docx Updated: 1/17/2014