Building_Permit_Permit_Application_2020 (3.9.2020),p(, f y�yv
www.edmondswa.gov.
BUILDING PERMIT
APPLICATION
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For handouts, submittal requirements,
permit status and inspection
scheduling information go to:
PLEASE NOTE: Intake appointmgnts 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 professional,
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 Address: 1414 91h Ave N, Edmonds, WA 98020
Parcel: 00427800100100
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: AT&T - New Cingular Wireless PCS, LLC
C/O The Sundstone Condominium
Mailing Address: 1414 91h Ave, N Unit
City/State/Zip: Edmonds, WA 98020
Phone #:
Email: ML2946@att.com
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? U Yes x 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: AT&T - New Cingular Wireless PCS, LLC
c/o Felicia Sauls
Mailing Address: 19355 W 102" d Street
City/State/Zip: Lenexa, KS 66220
Phone #:913-226-7438
E-mail: Felicia.Sauls@kgpco.com
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: Bluestream Professional Services, LLC_
Mailing Address: 3305 Hwy 60 West
City/State/Zip: Fairbault, MN 55021
Phone #: 814-312-2372
E-mail: dustin.queen@kgpco.com
STATE UBI #: 603209450
CITY OF EDMONDS BUSINESS LICENSE #: 603209450
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE: 603-
U Accessory Structure/
Detached Garage
U Addition
U Demolition
X Mechanical
U New Single Family / Duplex
U Plumbing
U Fire Sprinkler
U Remodel
U New Commercial/ Mixed Use
U Re -Roof
U Signs
U Tank
U Tenant Improvement
U 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: $9200
NEW
Basement sq ft:
Finished U Unfinished U
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
Installing diesel generator at existing cell site
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: Felicia Sauls
Signature: FeUcwSat44 Date 3 9 2020
Occupancy Group(s)
Type(s) of Construction
Occupant Load(s):
Fire Sprinklers: Yes LI No LI
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:
FIXTURE
Qty
COUNTSPLUMBING • or .•.
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/FUIEL 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
(New, Relocated or re -piped)
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 LI Conditional Waiver LI Waiver LI
Fill in Place LI Fill Material:
Removal LI
Size of Tank Gallons
Critical Areas Determination:
Study Required LI Conditional Waiver LI Waiver LI
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes LI No LI
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.