20160318101610.pdfV11 I DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft Fax 425.771.0221
City of Edmonds M'
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite City State, Zip):
Parcel #:
rn#,
,Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes❑ No
APPLICANT:
Phone: � ( Fax:
Address (Street, City, State, Zi
�5�'i
E -Mail Address:
.�. � � X75 — e _. _ � ,. =- ✓11�
PROPERTY OWNER: ` C 1
Phone: Fax
Address (Street, City, State, Zip): l t ,
E -Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*V ra
Phone: Fax:,
Address (Street, City, State, Zip): E -Mail Address:
1,scense
_�
must have a valid City of Edmonds business license prior to doing work " tIz r q gpDt
in the City. Contact the City Clerk's Office at 425.775.2525 City Business License 11I1''.% Date.
PLUMBING MECHANICAL TANK DEMOLITION
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............. ........_..._ _... — r s lll�a'.�' t
DETAIL THE SCOPE OF WORK: _........w ,. � `� �U Q °� _
I declare under penalty of perjury laws that the information I have provided on this form/application is true, correct and complete,
and that I am the property owner or duly authorized agent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: - i. ......" ..." Owner ❑ Agent/Other (specify)°-,
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Signature: :���� °e...--.�"... Date:
FORM C LABuilding New Folder 2010U70NE & x -(erred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
Fixture Type (new and relocated)
Total # Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
Pressure Reduction Valve/Pressure Regulator
Furnace
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Water Service Line
-Other: Other: # BTUs: <100k,,.,,- >100k
Tub/Shower
Drinking Fountain
Air Handler / VAV
Dishwasher
Clothes Washer
Other: #_ CFM: <10k— >10k,_wwwww_
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
(circle selected)
_...-_,....._ � -�-
Water Heater Tankless? Yes ❑ No ❑
_ W _ __� ..... . ..... .�
Hydronic Heat in: Floor ❑ Wall ❑
Boiler
Floor Drain/Floor Sink
Other:
AC / Compressor /
Refrigerator water supply (ror water/ice dispenser)
Other:
_
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #,_
Elec #-
-Other: Other: # BTUs: <100k,,.,,- >100k
Location(s)
Furnace
Air Handler / VAV
Gas #
#„_
Other: #_ CFM: <10k— >10k,_wwwww_
Location(s).........
(circle selected)
mm,
ITElec
Boiler
........
BTUs:.
AC / Compressor /
._..
Other:
_
BTUs:..,._.......,
Location(s):, ,,.
Boiler / Heat Pump /
Gas #...__-Elec
#..........O(lwr.,
�,., �. -- # BTUs:_......_............_._. <100k, ...................................
100k-500k,..................................500k-1Mil
Roof Top Unit
HP: ___<3,
3-15, 15-30 Location(s)
Dryer
(circle selected)
Outdoor BBQ
Hydronic Heating
Gas #
,,,,Elec #In
-Floor Wall Radiant— Boiler BTUs
I ocation _......
TOTAL OUTLETS
Exhaust Fans (single
Bath #
##
duct)
........................Kitchen
............. ......_Laundry —.Iftlxer:rw- ................
-_..
Fireplace
Gas #,_......Elec
#
-,_ )ther;..,�,,,,,, m #,_ Location(s),w...........................�......�..
Dryer Duct 7177
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: ._-......................................�.............
Location(s): .............................._...............................A..-_
Furnace
BTUs:
Locations):- ..__-..._-mmm_._.,,,,
Water Heater
BTUs: -w
Location(s):,
Boiler
BTUs:.
.... Location(s):-.._____......... _-
._..
Other:
_
BTUs:..,._.......,
Location(s):, ,,.
Fireplace/Insert
�..------ ......
BTUs:..Aw
Location(s):.
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014,docx Updated: 1/17/2014
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
Fill in Place [I Fill Material-,-,,,,-.-- Fill in Place r] Fill Material_,,, ,m_ ,,,,,,,,,,,
.._ ........
Removal �µ Removal
Number of Gallons: Number of Gallons
_......... ... .....�
Critical Areas Determination: Study Required Conditional Waiver ❑ Waiver
FORM C L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
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