ApplicationBUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswo.aov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildinaoermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address'133o mand Fk r S W
Parcel: 00 5 t 3 ) 00 0 \ 3 10 C1
Lot /Unit/Suite M Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: A.A M M- 1Sam ofa,
Mailing Address: -j1 33n 1'7;) n/t ST•pp��,,S\J
City/State/Zip: L CU µOrYAS. \A)A 91.tJ.�(o
Phone #: L1425) la - 71-)
Email:M_,KZCCLMa(-a_ Q kokIAa:%\• Co It'd
OWNER INSTALLATION: "If yes, read and sign"
Will work be performed by the property owner? ❑yes Fx]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: .teiiDr./1J
APPLICANT/ CONTACT INFORMATION:
Name of Applicant: Hide S1M0ra,
Mailing Address:1330 l /o.10 S�, SW
Ch
City/State/�Zri�p:'F_Ama 1Si WA 98oa(o
Phone #: as) x c)- )-))-)q
E-mail: N1,kPG,tmorek-0 64-M,I•CoM
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 M (CCB) & EXPIRATION DATE:
Permit #
❑Accessory Structure/ ❑
Detached Garage Addition
Demolition Mechanical
❑ New Single Family/Duplex 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.
Valuation:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished❑ Unfinished
1st Floor, sq ft:
2nd Floor, sqft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms:
DESCRIPTIONPROJECT
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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. ,/ j �1 �+
Print Name: I"I i//C��yeef A. ,>amor4,
SignatureTUVAoj�fQ/ Date
GENERAL• 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 EQUIPMENT COUNTS (New and Relocated)
BTUs Gas / Elec / Other MY
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• Relocated ore piped)
My My
Clothes Washer
Tub/ Showers
Dishwasher
Backfiow 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/FUEL• • •UNTS (New, Relocated or
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ / Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace Other:
MEDICAL A • • VACUUM COUNTS
Relocated or - • •
M7 M1
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? Ya/ N[]
PSCAA Case #:
Critical Areas Determination:
Study Required ❑ Conditional Waiver Waiver❑
A
Fill in Place ❑ Fill Material:
Removal ❑
Size of Tank (Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
•.a
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes No
GENERALPROVISIONS
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.