20161206105927.pdf�yh �" DEVELOPMENT SERVICES
RESIDENTIAL, RUIL,DING PERMIT
a APPLICATION
121 5"' Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 !& Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PRO ECT AW4ESS (Street, Suite # City State, Zip):
Parcel #:
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Subdivision/Lot #:
Prt`t Valuation: $
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APPLICANT:
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Phone: ✓✓�}
Fax:
Address (Street, City, State, Zip):
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PROPERT_ Y OWNER:
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Phone:
Fax:
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Address (Street i y State, Zip):
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E-Mail Address;
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LENDING AGENCY:
Phone: Faxc
Address (Street, City, State, Zip).
E-Mail Address:
CO TRACTOR:*
Phone. Fax:
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Addr"s (Street, City, State, Zip,�y .w
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E-Mail Address;
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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
1 City Business License #/Exp. Date:
DETAILTHE SCOPE QF WORK:
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PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: _ s . ft. Select Basement T e: Finished _ Unfinished
I" Floor: _ .,.. � _ _ _ _ s . ft. Gara e/Car ort: �._. � r- s . ft.
2"' Floor: ft. Deck/Cvrd Porch/Patio: _a „ s . ft.
Bedrooms #Full-3/4
_..... ��-
. .�.. Full 3/4 Bath # Half -Bath # ..m,..._. Other ........_-..�.__ .. ... ................ s . ft.
Fire S rinklers: Yes No 171 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: Owner El Agent/Other (specify): l ✓ c� ✓
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Signature: - t... �� Date ..... _ .....-.n ..,_
FORM A [.1t3w fld6ng New Folder72( IMONE & x-ferred to L.-Building-New driveAForm A2014.doex Updated: 1/17/2014