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HOUGHTAILING Mechanical Permit ApplicationBUILDING PERMIT Office Use Only APPLICATION Permit #: Development Services Building Division 121 5th Ave N / Edmonds, WA 98020 425.771.0220 For handouts, submittal requirements, permit status and inspection scheduling information go to: www.edmondswastov. PLEASE NOTE: Intake appointments are required for New Single Family Residences, Large Additions, ADU's, New Commercial, and Major Tenant Improvement application submittals. If plans are prepared by a profession- al, electronic files are requested in addition to the hard copies. Please bring electronic files on a flash drive or coordinate for electronic transfer. Please call 425-771-0220 to schedule an intake appointment! JOB SITE INFORMATION/LOCATION: (Where the work is taking )place) // Job Site Address: CO q t 13 1'A WACrw Parcel: Lot /Unit/Suite #: -7— Subdivision: PROPERTY OWNER: � �Y1/ Name: '5,6 1 -6L46 H l AI Ll AJ6 Mailing Address: (p qI % N WAy W City/State/Zip:QM+��QS Phone #: Email: OWNER INSTALLATION: *If yes, read and sign* Will work be performed by the property owner? ❑ Yes ❑ No I own, reside in, or will reside in the completed structure. This installation is being made on property that I own which is not intended for sale, lease, rent, or exchange according to RCW 18.27.090. Owner Signature: APPLICANT / CONTACT INFORMATION: � Name of Applicant: _fWl A/11r12,-- okVaky. CF Mailing Address: ��� �l',3 � N ) CJL) City/State/Zip: Gi1I¢41y,�f� Phone #: 411,�( E-mail: Jld1-I�>ANT/ i(J� �/ J.t' /140J,InAl GENERAL CONTRACTOR: (If different from applicant) General Contractor: Mailing Address: City/State/Zip: Phone #: E-mail: STATE UBI #: CITY OF EDMONDS BUSINESS LICENSE #: WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE: TYPE OF Details ❑ Accessory Structure/ ❑Addition Detached Garage ❑ Demolition XVlechanical ❑ New Single Family / Duplex ❑ Plumbing ❑ Fire Sprinkler ❑ Remodel ❑ New Commercial/ Mixed Use ❑ Re -Roof ❑ Signs ❑ Tank ❑ Tenant Improvement ❑ Other Remodel Permit fees are based on: The value of the work performed. Indicate the value (rounded to the nearest dollar) of all equipment, materials, labor, overhead, and the profit for fthe work indicated on this application. Valuation: PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION Basement sq ft: Finished ❑ Unfinished ❑ 1st Floor, sq ft: 2nd Floor, sq ft: Garage/Carport:, sq ft: Deck/Covered Porch/Patio: Other sq ft: PROJECTDESCRIPTION I certify 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. r± + Print Name: �AF- Signature: Date COMMERCIALGENERAL DATA Occupancy Group(s): Occupant Load(s): Type(s) of Construction: Fire Sprinklers: Yes ❑ No ❑ WA STATE ENERGY CODE: If your project affects the building envelope, mechanical systems, and/or lighting, you must complete the appropriate WSEC forms. DEFERRED SUBMITTALS: All commercial building permits that will require associated plumbing, mechanical, fire sprinkler, and/or fire alarm permits are applied for separately. TI / CHANGE OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet EQUIPMENTMECHANICAL • BTUs Gas / Elec / Other Qty A/C Unit /Compressor Air Handler /VAV Boiler Dryer Duct Exhaust Fans Fireplace Furnace Heat Pump Unit Hydronic Heating Roof Top Unit (Provide eleva- tions if a Commercial Bldg) Other: COUNTSPLUMBING FIXTURE .•. Qty Qty Clothes Washer Tub/ Showers Dishwasher Backflow Device (RPBA, DCDA, AVB) Drinking Fountain Pressure Reduction/ Regulator Valve Floor Drain/Sink Refrigerator Water Supply Hose Bibs Water Heater - Tankless? Y or N Hydronic Heat Water Service Line Sinks Other: Toilets Other: CONNECTION COUNTSor ..•. BTUs Qty BTUs Qty A/C Unit Outdoor BBQ/ Fire pit Boiler Stove/Range/Oven Dryer Water Heater Fireplace/ Insert LVv l Other: 1 Furnace Other: MEDICAL• (New, Relocated or • .•• Qty Qty Carbon Dioxide Nitrous Oxide Helium Oxygen Medical Air Other: Medical - Surgical Vacuum Other: DEMOLITION Type of structure to be demolished: Square footage of structure to be demolished: AHERA Survey done? Y / N PSCAA Case #: Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑ Fill in Place ❑ Fill Material: Removal ❑ Size of Tank (Gallons) Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑ GRADE/FILL/EXCAVATE Grading: Cut cubic yards Fill cubic yards Cut / Fill in Critical Area: Yes ❑ No ❑ GENERAL PROVISIONS APPLICATIONS: Applications are valid for a maximum of 1 year. ESLHA Applications, 2 years. LICENSING: All contractors and subcontractors are required to be licensed with Washington State Department of Labor & Industries and have a current City of Edmonds Business License.