APPLICATION BLD2020-0278 (2)Inc. I %WO
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.eamondswa.go .
PLEASE Intake appointments are required for New Single Family
Residences, LoW 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 call42S-771-0220 to schedule an intake appolntmend
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address:
Parcel: 210 32 4 M4 14 QQ
Lot/Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: D141,11i5L AMA T1zES514 KENTNSK
Mailing Address: bQto n
City/State/Zip:
Phone #: - b QZ
Email: M41BL• M NTNiM @ VJ%A0Q-COM
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:
I• i s lq M O N -t-I� Gv 0
Name of Applicant:
Mailing Address: 2 OZ b h40 # 1 I
city/State/Zip: EMdQN h 5 t B !I P-02 Q
Phone #: - 3
E-mail: 1 " 1•-1 Z C--H 1i 7Q'57, CGM
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: rg9LI�S LE;' C LR,551 C- 4-1rpMF"-1
Mailing Address: 43 57 3 I SI Vi AV C iq l
City/State/Zip: 4KI TI" , W 4 "143 I I�-
Phone#: 2016- 749 - �as3
E-mail:
STATE UBI #: 0 0 2 2 5 0 4 I'O a
aTY OF EDIIAONDS BUSINESS UCENSE #:
WA STATE CONTRACTOR L & 1 M (CCB) & EXPIRATION DATE:
N+9L (CW6%1 12L
Permit #: ^) % C l r-
❑ Accessory Structure/
Detached Garage
❑ Addition
1S] Demolition
❑ Mechanical
LkNew Single Family / Duplex
❑ Plumbing
❑ Fire Sprinkler
n Remodel
❑ New Commercial/ Mixed Use
❑ Re -Roof
❑ Signs
❑ Tank
❑ Tenant Improvement
❑ Other
Remodel Perna f 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 SOUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: a�j j . Finished 19 Unfinished ❑
1st Floor, sq ft:
1 5 (3 _5
2nd Floor, sq ft:
154.1
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio: 2139. -1
Other sq ft:
� ��M 0 _CIS -3 5�•
t^ousr�u cat` 1..rw `I,I 9 4_ I 5 F
(A3011LK2 I AYE DMB pRr=M)r t0 Br. --
_1S�.Il�'1'�
f � r�+o2 ~vct m ra y 15 , zoz QA -
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 j
Edmonds.
1 Print Name: Q- K � sv�. � �r,d� 1�l P!'
Signature: i _ .1.. Date
j
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 .Relocated)
BTUs Gas / Elec / Other Qty
A/C Unit/Compressor
Air Handler /VAV
Boiler)
I
Dryer Duct
Exhaust Fans
f1
Fireplace
C10
2-
Furnace
Heat Pump Unit
Hydronic Heating
Its -U13
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE -
Ctty City
Clothes Washer
j
Tub/ Showers
z
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,
uAS/ FUEL CON-JECTID'N COU %'S 'New, Relocated or re-pipedl
BTUs City BTUs City
A/C Unit
Outdoor BBQ / Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
I
Fireplace/ Insert
Z
Other:
1
Furnace j Other:
MEDICAL
(Nev), Relocated or' e.
MY
City
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum Other:
Type of structure to be demolished: $ , r 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 cubic yards
Cut / Fill in Critical Area: Yes ❑ NoF
GENERAL
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.