APPLICATION BLD2020-0278Irie. 10"
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 981M
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edmondswa.gov.
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 call 425-771-0220 to schedule an intake appolntmend
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: -1301rr C A ley 12D
Parcel: 27-032 4 M4 14 000
Lot/Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: D141,11i5L AMO T1zES514 KENTNSK
Mailing Address: 006 C Y} IZY FZ0
City/State/2ip: t hM ON 0M, 1n/ Y�, 9 ?7 02- D
Phone#: (-(pZ(L9) 3813 - ioyoz
Email: DANIEL• Ke NTNt12 O ` PNi0Q-rQH
OWNER INSTALLATION: 'If yes, read and sign"
Will work be performed by the property owner? ❑ Yes 14 No
1 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:
LIslq MON-1`41-Lv0
Name of Applicant: N' 7,V7 l9 F -C+f- ) T F t; T7a ie art DES 1-4-A rl
Mailing Address: 24 OZ O U DNON Q.S I, aU #- 11
city/State/7ip: 1=1)HC)pJ '7.5, ),t f) !2 F�02 O
Phone #: 2 0L) - S Li2 52.
E-mail: l 1Sk7 k N2►-)YJJOCHtT�CTS.COM
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: r 13 9 W 5 LE;' r t R,551 C- 4•1'DMF5
Mailing Address: 43 57 3 I S11i AV 2 iq i -1
city/state/Zip: 4��KI TI" , W 4 "143113-
Phone#: 2016- 7401 - �2.53
E-mail:
STATE UBI #: 0 0 2 2 5 0 W !o D
aTY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & 1 M (CCB) & EXPIRATION DATE:
C149L 1CW6 31 12L
Permit #
❑ Accessory Structure/
Detached Garage
❑ Addition
1S1 Demolition
❑ Mechanical
LkNew Single Family / Duplex
❑ Plumbing
❑ Fire Sprinkler
n Remodel
❑ New Commercial/ Mixed Use
❑ Re -Roof
❑ Signs
❑ Tank
❑ Tenant Improvement
❑ Other
Remodel Perrnit 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 irxGcated on this appliccatim.
Valuation:
PROPOSED NEW SOUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished N Unfinished ❑
1st Floor, sq ft:
15 13 ✓
2nd Floor, sq ft:
154.1
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio: 2139. 1
Other sq ft:
N MO P)IISII P46i Q 5-14;-3 3F 5,74-.
j t^.QS617','.JLA-- 1.IJC-w y,IL44• I 5F
i
I
A 0 K) LAI-E VEM 0 pert Ir 1 B
1ssu im �41aYz -Tb k3U 1 uQ11,Jb FJh1 rr
i
I k)P-102 72' N119-y 151-t2-oZ o )A
i
1 certify that the information I have provided on this form/application is true,
correct and complete, and that 1 am the property owner or duly authorized
agent of the property owner to submit a permit application to the City of
Edmonds.
I
Print Name: t�.0 g4 j ,I e
Signature: C �r 1% «, 7�yi Date r 'wl'
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 City
A/C Unit/Compressor
Air Handler /VAV
Boiler) I
Dryer Duct
Exhaust Fans f1
Fireplace C10 Z
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURIF . .re-w.pedl
Ctty City
Clothes Washer Tub/ Showers 2
Dishwasher Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain Pressure Reduction/ Regulator Valve
Floor Drain/Sink Refrigerator Water Supply
Hose Bibs Water Heater - Tankless? Y of N9
Hydronic Heat Water Service Line
Sinks 8 Other:
Tailptc d3thor,
BTUs City BTUs City
A/C Unit Outdoor BBQ / Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater I
Fireplace/ Insert Z Other:
Furnace I l l Other: I I I
City
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum
Other:
Type of structure to be demolished: $ , K .
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 25 cubic yards
Fill 245 cubic yards
Cut / Fill in Critical Area: Yes ❑ NoF
APPUCATIONS: 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.