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APPLICATION
r
Development Services
Building Division
721 5th Ave N / Edmonds, WA 98020
In -C -71 S-')0 426.771.0220
For handouts, submittal requirements go to: www.edmondswa.gov.
Ta apply forpermits, schedule inspections, or check application status
go to: www.mybuildingpermit.com
JOB SITE INFORMATION/LOCATION: (where the work is taking place)
Job site Address: 18308 84th PLACE W
Parcel: 005960-000-003-00
Lot /Unit/Suite #:. Subdivision: TER MAR
BUSINESS OR PROPERTY OWNER:
Name: Railin & Christian Santiago
Mailing Address: 18308 84th Place W
city/state/zip: Edmonds, WA 98026
Phone #: 360-790-1288
Email: ChristianSantiago23@gmaii.com
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner?RlyesFINo
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: Maya Mincemoyer
Mailing Address: 623 NW 83rd St
city/state/zip: Seattle, WA 98117
Phone #: 206-228-4225
E-mail: Mayamincemoyer@gmail.com
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:
City/State/zip:
Phone #:
E-mail:
STATE U BI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
Permit #:
TYPE OF PERMIT (Piovide
Details on Page
n Accessory Structure/
Addition
L� Detached Garage
Demolition
Mechanical
New Single Family/Duplex
Plumbing
ElFire 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: $3,900
PROPOSED NEW SQUAREFOOTAGE ■• THIS APPLICATION
Basement sq ft: Finished❑ Unfinished ❑
1st Floor, sti ft:
109
2nd Floor, sgft:
Garage/Carport:, sq ft:
-1 09
Deck/Covered Porch/Patio:
#of NEW Bedrooms: #of NEW Bathrooms:
PROJECTDESCRIPTION
—Add a 109 s.f_ playroom off of the
— living room into the garage area. A
window will be added to the
playroom. All work to be within the
—existing exterior Walls.
certify that the information I have provided on thi5 form application is true,
1 correct and complete, and that I am the property ownor or duly authorized
I
agent or the property owner to submit a permit application to the City of
Edmonds.
Print Name: Maya Mincemoyer
Signature: ate
COMMERCIALGENERAL
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
EQUIPMENTMECHANICAL •
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor
0
Air Handler /VAV
0
Boiler
0
Dryer Duct
0
Exhaust Fans
0
Fireplace
0
Furnace
0
Heat Pump Unit
0
Hydronic Heating
0
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
00
Other:
00
COUNTSPLUMBING FIXTURE
Qty Qty
Clothes Washer
0
Tub/ Showers
0
Dishwasher
0
Backflow Device (RPBA, DCDA, AVB)
0
Drinking Fountain
0
Pressure Reduction/ Regulator Valve
0
Floor Drain/Sink
0
Refrigerator Water Supply
0
Hose Bibs
0
Water Heater - Tankless? Y or N
0
Hydronic Heat
0
Water Service Line
0
Sinks
0
Other:
0
Toilets
0
Other:
0
COUNTSGAS/FUIEL CONNECTION d or re piped)
BTUs Qty BTUs
Qty
A/C Unit
0 Outdoor BBC,/ Fire pit
0
Boiler
0 Stove/Range/Oven
0
Dryer
0 Water Heater
0
Fireplace/ Insert
0 Other:
0
Furnace
0 Other:
0
COUNTSMEDICAL GAS, AIR VACUUM
(New, Relocated or re piped)
Qty Qty
Carbon Dioxide
0
Nitrous Oxide
0
Helium
0
Oxygen
0
Medical Air
0
Other:
Medical - Surgical Vacuum
0
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 ❑ Conditional Waiver ❑ Waiver❑
Fill in Place ❑ Fill Material:
Removal ❑
Size of Tank (Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
GRADE/FILL/EXCAVATE
Grading: Cut 0 cubic yards
Fill 0 cubic yards
Cut / Fill in Critical Area: Yes ❑ No
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.