20161216122851.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds I Phone 425.771.0220ft Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
RO Itr:'CT ADDRESS (Street, Suite # City State, Zip):
Parcel #:
L A
Y z 0
Subdivision/Lot #:
Project Valuation: $
APPLICANT: j
Phone:
Fax:
t, . yip). Address (Street, Cit „State, l"
E-Mail Address:�a
PROPERTY OWNER:
Phone: Fax;
Address (Street, City, State, Zip):
E-Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* r�
Phone:
Fax:
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 Business License #/Exp. Date:
DETAIL THE SCOPE OF WORK: D O
PROPOSED NEWS UARE FOOTAGE
FOR THIS PROJECT:
Basement: s . ft.
Select Basement Type: Finished Unfinished
V Floor: , ft.
Gara e/Car ort: s . ft.
2 Ild Floor: s . ft.
Deck/Cvrd Porch/Patio: s . ft.
Bedrooms # � Full-3/4 Bath # Half -Bath #
Other: -sq. ft.
Fire S rinklers: Yes LJ No 71
Retaining Wall: Yes 0 No
Grading: Cut _IT _,mm ITITIT cu. yds. Fill ,..., cu. ds.
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: J-4-0 tV { `� IT -��
Owner QAgent/Other ❑ (specify): ,.., ...... _...........................
Z_
Signature: :''
Date:
FORM A LABuilding New Folder 2010\DONE & x-ferred to L-Building-New driveTorm A2014.doex Updated: 1/17/2014