applicationp
�A 0 En,yo� BUILDING PERMIT
APPUCATION
Development Setvices
guiding Division
121 Stir Ave N / Edrnorlds, WA 98020
42;.771 nrn
For handouts, submittal requirements, permit status and Inspection
scheduling information go to: www.etimof)dswa.gov. . -
PLEASE NOTE: Intake appointments are required for New Single Family
Residences, Large Additions, ADU's, New Commercial, and Major -fenant
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 an a flash drive or coordinate for electronic transfer.
Pease cVH 425-M-0Z20 toschedule den hrtake oppo►ufinentf
JOB SITE INFORMATION/LOCATION:``(Where the work istakbtg place)
Job Site Address;
Parcel: 00(o I OA 0 a7 QQ :7-01 ------
Lot /Unit/Suite #: Subdivision:
PROPERTY IO,tWNIER: �j t
Name: t- + S/ih�.4C� ` r a $h _ l�tn�G� kYCS( MA))eol
Mailing Address: 1143 (oj L, eve 4
city/statep: v+�� tt�4 W A
Phone # ZO(r' - (iv 913 - 21 ib 72 _
Email: VAWI AjAe'! j bloUw - Lvm
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ Yes KNo
I own, reside in, or will reside in the completed str ctu re. This
installation is being made on propert hat I ich Is not
intended for sale, lease, r rding to RCW
18.27.090.
OwnerSiunaturc
APPLICANT/CONTACT IN ORMA7
Name of Applicant:_d
Mailing Address: �Z Z. 4A,
q
-City/State/Zip. a V1 o UJ A. ✓ �i —
Phone #: Zvi 3O " S Pa 05
E-mail: ' AiV--G Gk \(AIi1N7 , C0W✓�
GENERAL CONTRACTOR: (1f different from applicant
General Contractor:
Mailing Address:
City/State/Tip:
Phone M .
E-mail; ---
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & 1 #: [CCB) & EXPIRATION DATE:
❑ AccebsoryStructure/
Detached Garage 1Addition
❑ Demolition
❑ Mechanical
❑ New Single Family / Duplex
❑ Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use
'ts{Re-Roof
❑ Signs
❑ Tank
❑ Tenant Improvement ❑ Other
Remodel Permit fees are bused on:
The value of the work performed. Indicule the value (rounded to
the nearest dollar) of all equipment, materials, labor. overhead,
and the profit for the work indicated on this application. `
valuation: 35, 000
Basement sq Ift: Finished Unfinished ❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porcb/Patio:-
Other sq ft:
ii0mmiMENEW
rAof— of "'-A-r�,
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:
SFgrtaturs: ,�; u-a �. • � Gtate
COMMERCIALGENFRAL 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• •Relocated)
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor
0
Air Handler /VAV
0
Boiler
0
Dryer Duct
Exhaust Fans
Fireplace
Gas
1
Furnace
Gas
Heat Pump Unit
0
Hydronic Heating
0
Roof Top Unit (Provide eleva-
tions if a Commercial Bklg)
0
Other:
PLUMBING FIXTURE COUNTS iNeLk. Relocated or ..-
Qty Qty
Clothes Washer
Tub/ Showers
3
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
0
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Supply
Hose Bibs
4
Water Heater - Tankless? Y or N
n
Hydronic Heat
Water Service Line
Sinks
4
Other:
Toilets
4 1
Other:
CONNECTION• ..
BTUs My BTUs Qty
A/C Unit
Outdoor BBQ/Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
Other:
MEDICAL
GAS. AIR VACUUM •
(New, RelocateLl or r
Qty MY
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum Other:
• E M • •
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 ❑
GRAD E/Fl LL/ EXCAVATE
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No ❑
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.