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Application`11c. 189v BUILDING PERMIT Use Only APPLICATION I Permit #: Development Services Building Division 121 5th Ave N / Edmonds, WA 98020 425.771.0220 For handouts, submittal requirements go to: wimmedmondswa.aov. To apply for permits, schedule inspections, or check application status go to: www.mvbuildina�rmit.com JOB SITE INFORMATION/LOCATION: (where the workistaking place) Job Site Address: _I -jl:-1©3 Tr.` Oaf J10L Parcel: _ A ;2 72yz ,.7 a2/Dy/or!�7 Lot /Unit/Suite #: _F_ Subdivision: BUSINESS OR PROPERTY OWNER: Name: y Mailing Address: L 3 0 City/State/Zip: A Phone #: K5209� 72,Q —4493 x-Email: a OWNER INSTALLATION: *If yes, read and sign* Will work be performed by the property owner? ❑Yes ® No I own, reside in, or wilVr ompleted structure. This installation is being my that I own which is not intended for sate, leasan r I to RCW 18.27.090. Owner Signature: APPLICANT / CONTACT I_,� NFORMATIdW Name of Applicant: fINnza., Mailing Address: / zze:e3 City/State/Zip: x Phone #: x E-mail: GENERAL CONTRACTOR: (ifdifferentfrom applicant) General Contractor: ',J}y" Mailing Address- � �,¢�, /6/ City/State/Zip: Phone #: E-mail:T/y1�2� CmG�s�/. %f• STATE UBI #: (5 63 CITY OF EDMONDS BUSINESS LICENSE#:, WA STATE CONTRACTOR L & I M (CCB) & EXPIRATION DATE: TYPE OF ..- ❑Accessory Structure/ Additior4 Detached Garage 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 prof' or the work indicated on this application. Valuatio .�d�� PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION Basement sq ft: Finished Unfinished 1st Floor, sq ft: O j- 2nd Floor, sgft: �f S Garage/Carport:, sq ft: Deck/Covered Porch/Patio: 5F7 # of NEW Bedrooms: # of NEW Bathrooms: PROJECT I certify that the information I have ro i on i m pli 6if-�'t correct and complete, and that I am the property owner or duly authorized agent of the property ownerto submit a permit application to the City of Edmonds. Print Name: Signature:, 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 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: 2^4 Fw-io- = JVl%tSr`b%56✓� iV ' ' • 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 J Water Heater - Tankless? Y or N Hydronic Heat Water Service Line Sinks 2 Other: Toilets ' Other: CONNECTION• d 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 GAS, AIR VACUUM COUNTS d 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❑ . FmFww��� Fill in Place ❑ Fill Material: Removal Size of Tank (Gallons) Critical Areas Determination: Study Required Conditional Waiver Waiver •,EXCAVATE Grading: Cut 260 cubic yards Fill 130 cubic yards Cut / Fill in Critical Area: Yes ❑ No 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.