APPLICATION-8040 CYRUS PL•ni. Ilia.
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 Sth Ave N / Edmonds, WA 98020
425.771.0220
for handout, submittal requintmenb po to: ►Kww-edmvndswa.agv.
To apply for permits, schedule impecMons, or check application stotus
go to: wHw. yildinaP��rtit.tq/►t
JOB SITE INFORMATION/LOCATION: (Whe(e the work is taking place)
Job Site Address: q6VO Cmf /Z_
Parcel: QP-5-V 411(l0 O e 0 lip'- / �Ou,
Lot /Unit/Suite a: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name- r.t.16— Cif V&)DD
Mailing Address:?
Cary/state/zip: Aa—VM,4 &IDS' z,/h- FU'I
Phone d: .65V" Z' L) -- 2
Email: QQ C
OWNER INSTALLATION: *if yes, read an' sign•
Will work be performed by the property owner? Dyes WO
I own, reside in, or vrill reside in the completed structure. This
installation is being made on property that I oym which is not
intended for sale, lease, rent, or exchange according to RCW
18.2 7.090.
Owner S:g.n.ature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant:
Mailing Address�11.1,,S A-J' 4;1'-)'1J6
Gty/State/Zio:
Phone N-
E -mail:
GENERAL CONTRACTOR: (if ff
different from applicant)
General Contractor-� c �j-Ar ',r�i�,p
fvttiling Addre%v / extex Pe # 7 `��
City/State/Lp: _ f"/LL Ce41;j�-A ,1,/,+ 980/L
Phone 9: �(- — 1 - C
E-mail: G i C'Ort�
STATE U lu aY:
CITY OF EDMONDS BUSINESS LICENSE M:
WA STATE CONTRACTOR L & I a - (CCB) & EXPIRATION DATE:
6 y2- k3
—1 o C
a
Accessory Structure/
Detached Garage
Addition
Demolition
Mechanical
New Single Family/Duplex
a Plumbing
Fire Sprinkler
Remodel —
New Commercial/Mixed Use
Re -Roof
Signs
Tank
Tenant Improvement
Other
Remodel Permit fees orc based on:
Tr',e vak o of the work poriermed. Inoicote the vale a (rmnc*a to
the nearest doibr) of 01 equipment, fnaI* ids. ;oaor. overhood,
ord rno pror:t fa ire work IndicOtecl on this Oppiicotion.
VcluaHon: o
Basement sq tc Finished UnfimshedlLl—
1st Floor, sq R:
2nd Floor, sq h:
Garage/Carporc, sq R:
Deck/Covered Porch/Patio:
N of NEW Bedroorns: it of NEW Bathrooms:
.4
r� r
aiuC„s«K 1` d
I cerrty that the rnformaron I have / ` proNOed O.rl 1fptmyePGrKaMon true,
(greet and Mriplete, and that I am the prpp" orna or duly authoratd
agent Of the propertp inner to submit a permit application to t►►p C ty of
Ebnonds. `J
Print Name:
Signature: r- p
COMMERCIALGENERAL DATA
Occupancy Group(s) Occupant Lo d(s)
Type(s) of Construction:
Fife Sprinklers: Yes NO[]
WA STATE ENERGY CODE: If your project affects the building on"lope,
mechanical systems, and/or lighting, you must complete the
appropriate WSEC forms.
DEFERRED SUBMITTALS: AM commercial building permits that wii require
associated plumbing, mechanical, fire spmkler, and/or fire alarm
permits are applied for separately.
TI / CHANGE Of USE / NEW BLDG. Indude TRAFFIC IMPACT worksheet
NIKHANICAL EQUIPME?J COUNTS (New and Relocated)
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor
Air Handler /VAV
Boller
Dryer Duct
Exhaust Fans
Fireplace
/
Furnace
Heat Pump Un4
Hydronic Heating,
Roof Top Unit 1promda aw a-
ti0ns Of a Cognmer[Sal "I
Other
COUNTSPLUMBING FIXTURE
Qty Qty
Clothes Washer Tub/ Showers
Dishwasher BackAow Device (RPBA, DCOA, AVB)
Drinking fountain
Pressure Reduction/ Regulator V
Floor Draln/Sink
Refrigerator Water SSuupp
Hose Bibs
Water Neater - TjAkfess7 Y or N
Hydronic Heat
Water S"ce Line
Sinks
Toilets
Other:
CONNECTION COUNTSpiped)
BTUs Qty BTUs City
A/C Unit
Outdoor M / Fire pit
Boiler
Sta�e/Range/
Dryer
Water Ater
Fireplace/ insert r.
Furnace Other-
MEDICAL GAS, , ,COUNTSr re '
Relocated
_ CttY QtY
Carbon Dioxide Nitrous Oxide
Helium
n
Med.cal Air
Other:
Medical - Surgical Vacuum Other.
Type of structure to be demolished:
Stlluare footage of structure to be demolished:
AHERA Survey dona7 YD/ "U Case 4:
Critical Areas Determinatf
Study Requir Conditional Waiver❑ Waiver❑
F"ilin Place ❑ Fill Material:
Removal ❑
Tank (Gabon) e of
Critical Areas Determinatf .
Study Require Candrtanal Waiver Waiver
GRADE/FILLJEXCAVATF
Gradktig: Cut yards
CA Iit yards
Cut / FM in Critical Area: Yes No ❑
GENERAL PROVISIONS
APPLICATIONS: Applications are valid for a maximum of 1 year.
ESLHA Applications. 2 years
IICE NSING: All contractors and subcontractors are required to be licensed
with Washington State Department of Labor & Industries and have a
current City of Edmonds Buuness License.