APPLICATION.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
Ila APPLICATION
I S ety 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 A Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT,ADDRESS (Str et, SuRe #, City State, Zip): Parcel #:
Subdivision/Lot #: Project Valuation: $
APPLICEjNT Phone. Fax:
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Address ( to ert, 0ty ,Sta��:^, Zi p)' E -Mad Addre s:
4 . V ~
PROPE TY OWNER: V lruon :, Fax:
CA 10 Y "�q' �� 'A o. p _ ° k �1 f ,�� B (.�J
1 E -Mail Address:
A��ltNlv�, i�°�iIvct, City, `�uatr.� 71 v).
u
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* Phone: Fax:
if LL It
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 , "
a
PROPOSED NEW S DARE FOOTAGE FOR THIS_ PRO,rFXT:
11 Basement: e.e.W sq. ft. Select Basement T e: Finished U Unfinished
I" Floor: —S2., ft. Gara e/Car ort: - ........ �mm sq. ft.
2"" Floor:._ �-_ _.. ..... _ sq. ft. Deck/Cvrd Porch/Patio: ,�. ,._.._..._._.
Bedrooms #—_,. Full -3/4 Bath # Half -Bath # Other: , -w......- sq. ft.
Fire S rinklers: Yes I I No Retaining Wall: Yes No
Grading: Cut cu. yds. Fill cu.yds. I Cut/Fill in Critical Area: Yes __. No
I declare under penalty of perjury laws that the information I have prpvided on this form/application is true, correct and
complete, and that I am the property owner or duly authorized a'gtg4t 'tithe property owner to submit a permit application to
the City of Edmonds
�� t, Iret �i At/Oth�er ❑ (specif
Print Name t. >� P Y)
r _Signature: �Date: _...._ r. _— I _
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FORM A LABuilding New Folder 2010\®CANE & x-ferred to L-Building,New drive\Forrn A2014.docx Updated: 1/17/2014