20161202152726.pdf-� DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
t. 121 5`rAvenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 9 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: $
APPI51(, i"rNT , Phone: I Fax:
r ® 2
Address (Street, City, State, Zip)q g Ott " , E-Mail Address:
PROPERTY OWNER: PhoneY F.
Address (Street, City, State, Zip): Uo E-Mail Address:
4 e
LENDING AGENCY: Phone:. Fax
Address (Street, City, State, Zip); E-Mail Address;;
CON' RAC"I`OR:* Phone: Fax:
406
Address (Street, City, State, 'p): E-Mail Address:
OVA State License #/Exp. Date:
*Contractor inust have a valid City of Edmonds business license prior to = g e...
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
I VPI
DETAIL THE SCOPE OF WORK:....4U6................-
�. °."., ...,.... ..... ....................___-_,,,-... _.. ... _
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: ___ ww.......... ....— s . ft. Select Basement Ty e: Finished Unfinished
1" Floor..... _......._ .............. .........sq. ft. Gara „e/Car ort,� _ . - .......� .. ,s . ft.
2nd Floor: ...._s . ft. Deck/Cvrd Porch/Patio: _ ._ ..,_s . ft.
Bedrooms #......... Ba
th .. .....
.ath # Half -Bath # ,., Other:......, _. �m._.�........ _. s . ft.
Fire Sprinklers: Yes No Re
tainin Wall: Yes No
Grading: Cut cu. yds. Fill cu.yds. Cut/Fill in Critical Area: Yes LJ 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: a- . .. L wr �t � .. r Owner RAgent/Other ❑ (specify) _ .......... .
It
Signature: i.. " ex ,1.-W� . ..... m Date:
FORM A LABuilding New Folder 2010\DONE & x-(erred to L-Building-New drive\Forrn A2014.doex Updated: 1/17/2014