LawrenceMechApp"C. I i%-,
BUILDING PERMIT
APPLICATION
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.edmondswi.gov.
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 call425-771-0220 to schedule an intake appointment!
JOB SITE INFORMATIOnnN/LOCATION: (Where the work is taking place)
Job Site Address: l o� j q I � A- - P L
Parcel: 00 (J- b (0 (-e OMOC> Q o<->
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER: I
Name: A0� V-\ _ t�l1J (c n C -L
Mailing Address: 1O` �2 `�- 'k� i�
City/State/Zip: � A► A,O " S
Phone #: ?jko O c)cll,,
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: Q_�{ `C.- y� Y�O--tr1
Mailing Address: A 10 O � \'3 AV,—
City/State/Zip: z�'t`p` a. Cl V�- \ ko16
Phone #: 9 O<o
E-mail:
GENERAL CONTRACTOR: (If different from applicant)
General Contractor_ •C.. V"\. &b
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE U B I #: �C.� `f' �� t? '
CITY OF EDMONDS BUSINESS LICENSE tt:
WA STATE CONTRACTOR L & I #: (CCB) & EX IRArl
TI N DATE:
CA
Office Use Only
TYPE OF PERMIT (Provide Details on Page 2)
❑ Accessory Structure/ ❑ Addition
Detached Garage
❑ Demolition 0-mechanical
❑ New Single Family / Duplex ❑ Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use
❑ Re -Roof
❑ Signs ❑ Tank
❑ Ten,rnt Improvement ❑ Other
FRenno
del Permit fees are based on:he
value of the work performed. Indicate the value (rounded to
the nearest dollar) of all equipment, materials, labor, overhead,
iand the profit for the work indicated on this application.
Valuation:
PROPOSED NEW SQUARE•• •• 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:
PROJECT•
C 0. C 91oc
-'� L_
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
Edmond%. I
Print Name. \ t L
Signature —�� Date`i d
GENERAL COMMERCIAL 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
MECHANICAL•COUNTS
BTUs Gas / le Other QtY
A/C Unit /Compressor
/Z 1 _ Y-\
J �?
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace
•o
Q ,
1
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:
GAS/FUEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ / Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace Other:
COUNTSMEDICAL GAS, AIR VACUUM
Relocated .
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 it:
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 ❑
•.D
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No ❑
GENERALPROVISIONS
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.