20160404102514.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5 1h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A 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 #:
112
H (3
_7033(.001 0 -70o
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No
Associated Permit #:
APPLICANT: N I V e(L-SA L- "PL -A c A -Y -o oL 1�, I NX
Phone: Fax:
'75-00
lefo.'762- 2 06 ° 762.• 7-7S`-1
Address (Street, City, State, Zip):
E -Mail Address:
o� L
PROPERTY OWNER:
if—OlAiiA (;,&s
Phone.. Fax:
q560
Adch-ess (Street, City, State, Zip). LAA 48OZ-G
E -Mail Address.
,/Va( 0 0 1,-,
LENDING AGENCY:
—er-4j,
'Phone, Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*
Phone: Fax:
0/i lvef-rA A-Ppuc*-mt_s, (NAC.
Z -CX, .14 ? - 7 S(36 -lo(,, 76 Z -7 -7 S7 7
Address (Street, City, Stale,'Z� Ap)
E -Mail Address.,
Q_ 'Yakeo -co-,
WA State Livens #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
1-73 72-5- JJUNIvEAT-09731
in the City. Contact the City Clerk's Office at 425.775.2525
City Business Li c'ense #/Exp. Date:
IN
MHUM1111=11HUR WPM
PL- - o2—z_1 t 12 t T6 I k,
PLUMBING MECHANICAL TANK X_1
DEMOLITION
DETAIL THE SCOPE OF WORK:
SA 1 %,C,-
V EN T 14- A -C-1
P (e C-_
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: Owner El Agent/Other X(specify): (0,v m4croog-
zo f
Signature: Date:
FORM C LABuilding New Folder 201 O\DONE & x-ferred to LBuilding-New drive\Form C 2014.doex Updated: 1/17/2014
Type of Gas/Air/Vacuum System (new and relocated)
Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical — Surgical Vacuum
Other.
TOTAL OUTLETS
TANK #1 TANK #2
__......... .__..._w...
Method of Abandonment Method of Abandonment
Fill in Place ❑ Fill 'Material Fill in Place ❑ Fill Material
.............. .._.......... ._ ..... _................. ................. _
Removal[� Removal
Number of Gallons: 3�00 Number of Gallons:
............... ......... ............. . ............ .. ......................
Critical Areas Determination: Study Required Conditional Waiver ❑ Waiver ❑
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 ❑ WaiverEl
LPSCAA Case No. AHERA Survey done? (required)dditional comments:
FORM C LABuilding New Folder 2010\130NE & x-ferred to LrBuilding-New drive\Form C 2014.docx Updated: 1/17/2014
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