20170825104837.pdfo,C E b n,v
Al
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
�•St I �9p 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 Q Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
YROJk,CT ADDRESS (S r Sui # City Sta e, ",ip):
Parcel #:
Subd�ivision/LottS#:
Project Valuation: $ /6
l t Ow, pit!
APPLICANT;— At/2-
r� 71mo'cl` L/& la
Phone:
�. 7XS k
Fax:
Address Ireet, City, State ):
E-Mail Address:
7,(4/" TS,,U�r
PRtQPERTY OWNER:
T// SC�fdlS7'�/L
Phone:
�6'-%T!"-tI66�
Fax:
Address (Street, City, tate, t )G:
-- 2-/ 0G
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, 74p :—
E-Mail Address:
CONTRACTOR:*
Phone:
Fax:
t
CZip):
Address (Street, City, State,
E-Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to
City Business License #/Exp. Date:
doing work in the City. Contact the City Clerk's Office at 425.775.2525
DETAIL THE SCOPE OF WORK —
PROPOSED NEWSQUARE FOOTAGE
FOR THIS PROJECT:
Basement: s . ft.
Select Basement "I e: Finished Unfinished
I" Floor: sc . ft.
Garage/Carport: _Sc. ft.
-7 Floor: st . ft.
Deck/Cvrd Porch/Patio: sc . ft.
Bedrooms # Full-3/4 Bath # Half -Bath #
Other: s . ft.
Fire Sprinklers: Yes
0
No
LJ
Retaining 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.
�/J,� S�WsTuG�
-
Print Name: 2/� Y(- Owner Agent/Other Q (specify):
/` G Date:
Signature: Ar''.t
FORM A LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014.doex Updated: 1/17/2014