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W DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK & DEMOLITION
PERMIT APPLICATION
1215'h Avenue N, Edmonds, WA 98020
r s`t t Phone 425.771.0220 It Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
$8 lq I -R 'i T ST SV -1
°l
-II -rr
2 W -7 1$ 00�a`t $00
�AM04t> S W1611 s02
Yes ❑ No
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT?
APPLICANT: v N 1 V E.(Z-lt�� ia'P Q �- I t PtTD (t- S, N L.
Phone: I Fax:
7,o(, •762.7 00 2,06.7GZ •715
Address (Street, City„, State, Zip):
So,�r'r 0_4 ST Srtl�r,f- WA �b10
E -Mail Address:
NA_r-WtAQ AkoO•COe
PROPERTY OWNER:
9-0 Snn -T *Jr
Phone: Fax:
4LS• 77S7•07-1 1
Address (Street„ City, State, Zip'):
E -Mail Address:
�
X51 t oft. i
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
. .
Fill in Place Material � Fill in Place . ... ......
E] Fill Material
Removal Removal
Number of Gallons: Number of Gallons:
_.�.. _... _... ._..� ....
Critical Areas Determination: Study Required Conditional Waiver El Waiver 0
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New driveTorm C 2014.docx Updated: 1/17/2014