APPLICATION.pdf'
Parcel #:
DEVELOPMENT SERVICES
Subdivist Lot #:
RESIDENTIAL BUILDING PERMIT
APPLICANT: t
Phone: Fax:
1ltidres (Street, City State, Zip): V
03 jz� Iz /-?
APPLICATION
-.11.
� 4
1 R PI+ "ry OWi�ER':
9
121 5h Avenue N, Edmonds, WA 98020
City of Edmonds
E -Mail Address:
Phone 425.771.0220 4. Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROpI..I,ee
ADDRESS (Street, Suite # City State, ip):
ja.
Parcel #:
() _AOld .3 C� 141
Subdivist Lot #:
Project Valuation: $
APPLICANT: t
Phone: Fax:
1ltidres (Street, City State, Zip): V
03 jz� Iz /-?
ail Address: 1
Ocs ilq 61VIqp L
LL -
-.11.
� 4
1 R PI+ "ry OWi�ER':
Phone. Fax:
Address (Street, City, State, Z'
E -Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
COLTRACTQR:* n
'I-',
Phone: Fax:
c� o ry
Address (Street, City, State, Zip):
E -Mail Address:
' 0 3
WA StateLicense. #1Lxp. Dat
*Contractor must have a valid City of Edmonds business license prior to "L)L: SS (L O �
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: ,m,;
PROPOSED NEWSQUARE FOOTAGE FOR THIS PROJECT:
Basement: __S2. ft. Select Basement T e: Finished LJ Unfinished LJ
1" Floor: .....WWW—- --sq. ft. Gara e/Car ort: .............................................._................ —s . ft.
2"d Floor: sq. ft. Deck/Cvrd Porch/Patio: .....—sq. ft.
Bedrooms Full -3/4 Bath # Half -Bath #�, Other: _ _ sq. ft.
Fire Sprinklers: Yes LJ No 0 Retainin Wall: Yes No 17
Grading: Cut cu. yds. Fill cu.yds. Cut/Fill in Critical Area: Yes L 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 Rro � owner or duly authorized agent of the property owner to submit a permit application to
the City of l "c' no ;
Print N, nc:., Owner ❑ Agent/Other ❑ (specify):
0 Signature: _ Date:
FORM A LABuilding New Folder 2010\130NE & x-ferred to "L -Building -New drive\Form A2014.docx Updated: 1/17/2014