20160413110721.pdfl7t` UL)
r, DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
,� 121 5`" Avenue N, Edmonds, WA 98020
S t. Phone 425.771.0220 ff 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 #:
Associated Permit #:
71STHIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT: Phone.. Fax:
Address (Street, City, State, Zip): E-Mail Address:
PROPERTY OWNER: I I Phone: Fax:
)Vii,sjen Gana lVafAort-e l yetV5�' 6-672-313
Address (Street, City, State, Zip): ul� E-'Mail Address:
8.25 SF Fdrnor s k)/ 1`'X i � G^.4i i 1 G� paa's �s
LENDING AGENCY: A 1/A Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
CONTRACTOR:* �• ` Phone: Fax:
'212P4
Address (Street, City, Slate, Zip): /E-Mail Address:
WA State License #lExp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
in the Cite. Contact the City Clerk's Office at 425.775.2525 City Bl s License #/Expry. Date:
PLUMBING MECHANICAL TANKI I DEMOLITION
DETAIL THE SCOPE OF WORK:
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: :' _ LOwner ❑ Agent/Other �:3 (specify):
Signature: _ . , . � Date: _� ^
FORM C L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
c�••L
PLUMBING
FIXTURE COUNT
FixtureType(new and relocated)
Total #
Fixture Type (new and relocated) Total #
Water Closet (Toilet)
Pressure Reduction Valve/PressureRegulator
Sink (kitchen, laundry, lavatory, bar, eyewash, etc.)
................_.___
Water Service Line
Tub/Showerm
Drinking Fountain
Dishwasher
Clothes Washer
.�
Hose Bib
....w._.............. _... �.
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
.._........ ....
Water Heater Tankless?Yes❑ No❑
_
Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Stink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
Equipment Type
. . . . . . . . ...................... .. ....... .. . . . . . . . .
MECHANICAL
Appliance(Equipment Information (new and relocated)
Total #
Furnace
Gas # Elec#—Other: # BTUs: <100k—>100k„_ Location(s)
Air Handier/ VAV
Gas# Elec# Other: # CFM: <10k >10k Location(s)
(cirdeselected)
— --
AC / Compressor /
Boiler/Heat Pump/
Gas#; Elec# Other: #_BTUsc <100k, 100k-500k, 500k-1MiI
Roof Top Unit
HP: <3, 3-15, 15-30 Location(s) ��1
(ci r d e sel eded)
Hydronic Heating
Gas#L�. Elec# In -Floor Wall Radiant Boiler BTUs: Location
Exhaust Fans (single
Bath# Kitchen# Laundry #_Other: #
dud)
Fireplace
Gas # Elec# Other: # Location(s)
Dryer Dud
I
Appliance Type
FUEL GAS
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
_
BTUs: Location(s):,
Furnace
BTUs: Location(s):
Water Heater
BTUs: Location(s):
Boiler
TUs: Location(s):
Other.;
....�.....
[BTUs:Location(s):
FireplaceJlnsert__.
BTUs: Location(s),
Stove/Range(Oven
_....._......_ __..... _
_m._ _ ....._.. _ ..m__
Dryer
. ........
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 201000NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014