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BLD2020-0559+City_Application+6.1.2020_4.04.53_PMBUILDING PERMIT APPLICATION Development Services Building Division 121 5th Ave N / Edmonds, WA 98020 'nc t gy'i 425.I f I.0220 For handouts, submittal requirements, permit status and inspection scheduling information go to: tivww.edmondswa.Rov. 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 call415-771-0110 to schedule an intake appointment! JOB SITE INFORMATION/LOCATION: (Where the work is taking place) Jab Site Address: -fm g 2. l G 01 5t-zf 5 W Parcel: 00 3 7a4,0040010 Lot /Unit/Suite #: Subdivision: 1414(u9444 MA -or PROPERTY OWNER: Name: �e-an L - Z4 #A� Mailing Address: 0101 City/State/Zip: �d Phone#: 2ois• `�Q� - $ �0Z Email: �la�r�ar' ®Gon��f, nel OWNER INSTALLATION: *If yes, read and sign* Will work be performed by the property owner? Z Yes ❑ 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, rer mchq4pge according to RCW 18.27.090. Owner Signature: APPLICANT / CONTACT ORMATION: Name of Applicant: &A 4, Ad 4 Mailing Address: 9;-fol SIG 0 6f-wf 5 w City/State/Zip: �"+a a ct) 4 g9o?-4 Phone #: Ze'>& - ' 9-f 0Z E-mail: A ash to,- , *t ® rw- GENERAL CONTRACTOR: (If different from applicant) General Contractor: Mailing Address:_ City/State/Zip: Phone #: E-mail: STATE UBI ##: CITY OF EDMONDS BUSINESS LICENSE #: WA STATE CONTRACTOR L & I ##: (CCB) & EXPIRATION DATE: Office Use Only TYPE OF PERMIT (Provide Details on Page 2) ❑ Accessory Structure/ 21ddition Detached Garage ❑ Demolition C'Mechanical ❑ New Single Family / Duplex 0'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. r Vnlrin4inn• $ 2: '7 coo. PROPOSED•• Basement sq ft: FOR THIS APPLICATION Finished ❑ Unfinished ❑ 1st Floor, sq ft: 1 2nd Floor, sq ft: Garage/Carport:, sq ft: Deck/Covered Porch/Patio: Other sq ft: PROJECT• ,���'� �1on a� Q` rti e�� bed'�lov.•. a n d G rGa -Nf!i 4; I certify that the information 1 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. c Print Name: �)eCt/t z- Signature: Date 9 • I. 2v GENERAL COMMERCIAL DATA Occupancy Group(s): Occupant Load(s): Type(s) of Construction: Fire Sprinklers: Yes ❑ No Z' 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 EQUIPMENT COUNTS (New and Relocated) 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: PLUMBING FIXTURE COUNTS (New, Relocated or re -piped) Qty City Clothes Washer Tub/Showers z Dishwasher Backfiow Device (RPBA, DCDA, AVB) Drinking Fountain Pressure Reduction/ Regulator Valve Floor Drain/Sink Refrigerator Water Supply Hose Bibs Water Heater-Tankless?©orN Hydronic Heat Water Service Line Sinks 'L Other: Toilets Other: BTUs City BTUs Qty A/C Unit Outdoor BBQ/ Fire pit Boiler Stove/Range/Oven Dryer Water Heater Fireplace/ Insert Other: I Furnace I I I Other: Carbon Dioxide Nitrous Oxide Helium Oxygen Medical Air Other: Medical • Surgical Vacuum Other: 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 ❑ Grading: Cut It cubic yards Fill cubic yards yf, ek%Sfi'^ Cut / FIII in Critical Area: Yes ❑ No IJ 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.