1811 86 PL W-SITE PLAN, APP.pdf6U)<30U_1H3q
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5" Avenue N, Edmonds, WA 98020
Phone 425.771.0220 Ift Fax 425.771.0221
C: of Eimonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLISTFOR SUBM17TAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
�L V(DRl GbA44,VD5 t44 q902&
60(o I 2-406M0300
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes E] No X
Associated Permit #:
APPLICANT:
LAIVI VT (15 At On I CA06o
Phone:
Zrl, 46 - -41MO
ax:
2-66--+64-175 0
Address tStfeet, City, State, Zip):
-5i!r r. soviHrayv 5T, 5f 1
E-Mail Address:
LIA-1 — k- W kj \j " Aln C 15 I -A
PROPERTY OWNER:
j"1F 5
Phone:
V - Iq s 3
Fax
A,idre.;s (Street. City, State, Zip):
11911 -L Vgt't- fl- K) - F-b,14j)AJD 5,W4 'I VO
E-Mail Address:
j Pa L4,+-L tQ PJ k_j +4 5 C A
LENDING AGENCY:
Phone:
Fa�
A id,72,�, Street. Cit). State, Zip):
E-Mail Address:
CONTRACTOR:*
tt " "I MAMV
Phone:
24%-:716 L 'Koo
FZ101:
2zYr - 41- 2 -
A Street. City, State. Zip):
d5i 1� 1. sou-ri1fVLJv VT. 2E7,21-1 LEE., yJA
E-Mail Address:
tAk I — V_W .1,� - C-0 k—,
a I alid Ciry of Edmonds business license prior to doing work
V_1 C!:- Con. -ac, the CirN Clerk's Office at 425.775.2525
W 'A State License d7lixp D-,,-
02�"
lily Business License =/Ex; D.��_-
'i
Lim - t -7 9 .72 r, /Z
PLUNIBLNG MECHANICAL TANK
DEMOLITION I
DETAIL THE SCOPE OF WORK: Z ReM&CEMEN-1 OF 2cep 6,!j_-L
tAjvt>Eftj2j2UAj> A"t4)r-^q1A-t_ fjF^71rj6 Off- Te'rWK.
I declare underpenalty ofpeijury laws that the information I have provided on this jormlapplication is true, correct and complf re.
and that I am the property owner or duly authorized agent of the property owner to submit a permit application to the Clj� of
Edmonds.
Pn,nt Name: Owner 0 ALent/Other specify): t0A1T_A*CnA_
S,znalure, Date: —"/2 r &
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T�ype of Gas/AirNacuum System (new and relocated)
Total#
0"VE
Vudt
Carbvn Dioidde
Ht"--um
NledkAl — Surgical Vacuum
Othtr:
I TOTAL OUTLETS
TANK #1
TANK #2
Method of Abandonment
Fill in Place
Method of Abandonment
Fill Material
FW in Place Fill Material
Removal
Removal
Number of Gallons: 36()
Number of Gallons:
Critical Areas Determination: Study Required Xj
Conditional Waiver F—I
Waiver F-I
Type of structure to be demolished (e.g. house, shed, garage, etc.):
Floor area of structure to be demolished: sq. ft.
Critical Areas Determination: Study Required Conditional Waiver Waiver El
PSCAA Case No. — I AHERA Survey done? (required)
Additional comments:
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