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Goldstein permit app revOV BUILDING PERMIT APPLICATION ' a z . Development Services - Building Division 121 5th Ave N / Edmonds, WA 98020 425.771.0220 For handouts, submittal requirements go to. www.edmondswa.gov. To apply for permits, schedule inspections, or check application status go to. www.mybuildingpermit.com JOB SITE INFORMATION/LOCATION: (Where the work is taking place) Job site address: 524 - 3rd Ave North Parcel: 27032400205800 Lot /Unit/Suite N: Subdivision: attached to )p an /t?ET—'1'SvAJT> 5 BUSINESS OR PROPERTY OWNER: Name: Steven Goldstein Mailing Address: 524 - 3rd Ave North City/State/zip: Edmonds WA 98020 Phone #: 206-719-6489 Email: steveg@cts-co.com OWNER INSTALLATION: *If yes, read and sign* Will work be performed by the property owner? ©Yes F] 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, re , or exchange according to RCW 18, 27.090. Owner Signature: APPLICANT / CONTACT INFORMATION: Name of Applicant: Al Cohen Mailing Address: 330 Dayton St #6 City/state/Zip: Edmonds WA 98020 Phone #: 425-776-7373 E-mail: alcohendesign@gmail.com GENERAL CONTRACTOR: (If different from applicant) General Contractor: TBD Mailing Address: City/State/Zip: Phone #: E-mail STATE UBI M CITY OF EDMONDS BUSINESS LICENSE M WA STATE CONTRACTOR L & 1 #: (CCB) & EXPIRATION DATE 7ev TYPE OF PERMIT (Provide Details on Page 2) 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 a 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, overheod. and the profit for the work indicated on this application. Valuation: 12,600 PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION Basement sq ft: Finished ElUnfinished 11 1st Floor, sq ft: 2nd Floor, sq ft: Garage/Carport:, sq ft: Deck/Covered Porch/Patio: 324 N of NEW Bedrooms: PROJECT• # of NEW Bathrooms: 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: Albert H Cohen Signature: �l - Date 8/11 /20 COMMERCIALGENERAL Occupancy Group(s): Occupant Load(s): Type(s) of Construction: Fire Sprinklers: Yes 0No0 WA STAI E 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 or re piped) Qty Qty Clothes Washer Tub/ Showers Dishwasher Backflow Device fRPBA, 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 Clty A/C Unit Outdoor BBQ / Fire pit % Boiler Stove/Range/Oven Dryer Water Heater Fireplace/ Insert Other: Furnace Other: COUNTSI MEDICAL GAS, AIR VACUUM d or re piped) Qty Qty Carbon Dioxide Nitrous Oxide Helium Oxygen Medical Air Other: Medical -Surgical Vacuum Other: DEMOLITION I Type of structure to be demolished: Wood and fiberglass porch roof Square footage of structure to be demolished: 160 AHERA Survey done? Y❑/ N❑ PSCAA Case ti: Critical Areas Determination: Study Required [:1 Conditional Waiver ❑ Waiver0 Fill in Place ❑ Fill Material: Removal ❑ I Size of Tank (Gallons) Critical Areas Determination: Study Required Conditional Waiver Waiver Grading: Cutcubicyards j Fill cubic yards Cut / Fill in Critical Area: Yes F] No11 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.