FIR2020-0078_City_Application_8.27.2020_12.44.24_PMInc. 18y"
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.edmondswa.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 INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address:. A PUt N CAMt S
Parcel: 1-103 ` A 00 2111D00
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: W�S A
Mailing Address: �b3 mQCh��1S(�►
City/State/Zip: GS 1n1��h���� ' `mo
Phone #: ��t l b \,L�3"1 15—i 4 r ^
Email: Y 1 L�11�@�kAMM • UM
OWNERINSTALLATION: *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. dis
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:7%:(N hcamv�
S bu 1/as
Mailing Address: " _
City/State/ZZiip: ^ h
Phone#: L\Q'- p�\ Ol1 -C t
E-mail:�`V�11VlN\\VIS�YIJpi).
GENERAL CONTRACTOR:: (if
different from applicant) �` T
General Contractor: ,1Q111C �S �l'�KJ�1 UA
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE UBI#:,M. Q�
CITY OF EDMONDS BUSINESS LICENSE #:Nk Q C.. "I
WA STATE CCV4TRACTOR L kI #: (CCB) & EXPIRATION DATE:
5
Office
Use Only
TYPE Of ..
❑ Accessory Structure/
❑ Addition
Detached Garage
❑ Demolition
❑ Mechanical
❑ 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 the 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./� ,
Print Name: U1n1 DU ms ��1Q C\,.■ 1
Signature: �Qy l A77 Date�1Yo
GENERAL COMMERCIAL DATA
Occupancy Group(s):. Occupan . t Load(s):
Type(s)* of Construction:
Fite Sprinklers: -Yes 0* Nol]
WA STATE ENERGY CODE: if your project.aftects.the building envelope,
mechanical tysterns,'andior lighting; you must c 0implete the
appropriate WSEC forms.
DEF1RRRED*SUBMITTALS: All commerclP . I.buildi rigipermits that will require
associated.:Plumbing; mechanical, fire* sprinkler, and/or fire alarm
permits are applied for separately:
TI / CHANGE OF USE NEW BLDGt Include TRAFFIC I M 0ACT.worksheet
MECHANICAL'EQUIPMENT C.0UNTS- (New and Relocated)
BTUs Gas*/ Elec /Other Qty
A/C* Unit /Compressor.
Air HandIer JVAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace.
Heat Pump Unit
HVdronic Heating*
Rodi'Top Unit. (Provide -eleva-
tions if a Commercial Bldg)
Other:
.. .... .. .. ............ . ... . ........
0 LU M RI N G F IXTU RE COUNTS (New, Relocated'or re -piped)
Qty* Qty*
clothes Washee
Tub/ Showers
Dishwasher
ffackflow Device (k06A.,-DCDA,.AVB)
Driniking Fountain
Pressure Red. uction/ Regulator. Valve
Floor-Drain/Sin.k.
Refrigerator Water -Suppi y
Hose Bibs
Water Heater -Tankless? YorN
Hydro.nic Heat
Water -Service :Line
Sinks
Other:
Toilets
Other:
GAS/FUEL CONNECTION C6UJYTS'(iYew;.ke'1oca . t'ed'or. re -piped)
BTUs Oty BTUs Qty
A/C.- U n i t
Outdoor-BBQ./ Fire pit
$011ler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace Other;
M EDICAL.-GAS,. AIR.:.VAC. U.0 M -CO U NTS
Qty
Qty
Carbon- Dioxide
Nitrous Oxide
Helium
oxygen
Medical Air
other.,
Medical 7 SiJijical Vacuum Other:
DEMOUT10 N
Type of structure to be demolished:
Square footage*of structure to be*Aeilnolished:
AHERA Survey.done?* Y N*
PSCAA Case.#:.
Critical Areas Determination:
Study.Required 0 :Conditional Waiver El Waiver 11
Fill in Place Fill Material:
-Removal.0
Size of tank (Gallons).
:Cr itical Areas Determination-.
Study Required 0. Cbriclitio.nal.Waiiver.0 Waiver 0
r?RADE/FILL/EXCAVATE
Grading: Cut - cubic yards
Fill cubic yards
Cut/. Fill in Critical Area., Yes.0 No 0
GENERAL PROVISIONS
APPLICATIONS: Applications are valid. for a. maximum of 1year.
ESLHA Applications, 2 years:
LICENSING; All contractors: arid s.ubco.ryt.racWrsare .required. to-be.licensed:
with Washington State Department of &Industries and have
-current* City of Edmonds Business License.