APPLICATION (2)'11c. 1 %`�"
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmandswa.gov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuddingpermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: ,^ D 6 /riU JtIdI'7L2p((}
Parcel: 9D3 %De)
Lot /Unit/Suite #: 3 Subdivision: 64+C D] 9 A —fJ_0
BUSINESS OR PROPERTY OWNER:
Name: &L M i oN Akre Hz�
Mailing Address: A 0 6 7-11
City/State/Zip: __&Lt?Q&Q S
Phone#:
Email;
OWNER INSTALLATION: *If and sign*
Will work be performed by the property owner? ®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, rent, or exchange according to RCW
18.27.090. % __
Owner Signature:C
APPLICANT / CONTACT INFORMATION:
Name of Applicant:
Mailing Address:
City/State/Zip:
Phone #: _
E-mail:
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:
OYYice Use (My
TYPE OF
Details ..
Accessory Structure/
Addition
El
Detached Garage
Demolition
Mechanical
New Single Family/Duplex
Plumbing
Fire Sprinkler
Remodel
Ei
New Commercial/Mixed Use
Re -Roof
❑ Signs
❑ Tank
❑ Tenant Improvement ® Other D i5eA
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:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION —
Basement sci ft: Finished ❑ Unfinished
1st Floor, sci ft:
2nd Floor, sci ft:
Garage/Carport:, sci ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms:
PROJECTDESCRIPTION
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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: t 4 ��
Signature Date
GENERAL COMMERCIAL 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
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 d or re piped)
Qty 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
Water Service Line
Hydronic Heat
Sinks
Other:
Toilets
Other:
CONNECTION COUNTSd 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:
MEDICAL•
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 ❑ 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 cubic yards
Fill 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 rontrartors-and subcontractors are required to he licensed
with Washington State Department of Labor & Industries and have a
current City of Edmonds Business License.