20160413142055.pdfN DEVELOPMENT SERVICES
PLUMBING & MECHANICAL, TANK & DEMOLITION
PERMIT APPLICATION
I Sl 1M\1 121 51h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 t 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 #:
9819 224th ST SW Edmonds 98020 00450700400014
APPLICANT:pphgo e: Fax:
Bob's Heatinq and A/C 80�-840-3346
Address (Street, City, State, Zip): E -Mail Address:
14148 NE 190th ST Woodinville Wa 98072 cflajole@bobsheatinq.com
PROPERTY OWNER: Phone: Fax
Greo Gadbois 425-419-6965
Address (Street, City, State, Zip):
E -Mail Address:
9819 224th ST SW Edmonds 98020
LENDING AGENCY:
Phone: Fax.
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*
P18`0-8
8:0
Bobs Heating and A/C
-840-3346Fax:
Address (Street, City, State, Zip):
License #/Exp. Date:
14148 NE 190th ST Woodinville Wa 98072
BOBSHHA853NO
kContracror must have a valid City of F_dmonrls bushiess license prior to doing work in the
CitR-014338 �Business License #/Exp. Date:
City, Contact the City Clerk's Office at 425.775.2525
NR— 014 3 3 8
I J PLUMBING 1 MECHANICAL i I TANK i I DrwOLITION
add ac to existing hvac system
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- Inda Hone ckAt J Owner
�X Agent/Other (specify):
Signature: Date: �
4/13/16
FORM C Q\Documents and Settings\bjorback\Desktop\Form Cdoc Updated: 10/2010
TANK #1
Appliance/Equipment Information (new and relocated) Total #
TANK #2
Number of Gallons,
..,,,, ,,__
Number of Gallons.. m,-
....Method.�of.�Abandonment ...._.m......._w � w ......................._....... .���_�
# Gas #AElec # Other:,_ ,—
Method of Abandonment...................�.__...........................�............_..................................................................
�_........w
❑ Fill in Place Fill Material
F
_
........._... .
❑ Fill in Place Fill Material
Pum Rinse & Cap
❑ P�
100k -500k, 500k-1Mil
❑ Pump, Rinse & Cap
Removal
Location
❑ Removal
..... m �.....................
Re
Critical Areas Determination: []Study.....Required
q
naver ❑Waiver
❑ Conditional Waiver
Equipment Type
Appliance/Equipment Information (new and relocated) Total #
Furnace
#_Gas # Elec # Other:
BTUs: <100k, >100k
� —
Location
Air Handler/ACNAV
# Gas #AElec # Other:,_ ,—
CFM: <100kA__>100k_
Locationt, -
Boiler/Compressor/
# Gas #_Elec #_Other:_
BTUs:—<l 00k,
100k -500k, 500k-1Mil
Heat Pump/Roof Top
Unit
HP: <3, 3-15, 15-30
Location
Hydronic Heating
#_Gas #_Elec —in -Floor, _Wall
Radiant, Boiler BTUs:_,,,.,,
Location
�r
Exhaust Fans (single
Location: #_Bath #_Kitchen
#_Laundry #, Other.
duct)
Fireplace
#_Gas #_Elec #_Other:
Location -
Number of Outlets
Fixture/Appliance Type
AC Unit -------------- BTUs:
Location,
�
Furnace -------------- BTUs:
Location:
WITmmmmmmmmmmmmm ITITmmmITITIT
m Water Heater - -- — BTUs:
Location:
Boiler -----------------BTUs:
Location:.
Fireplace/Insert BTUs:
Location:
-�
Stove/Range/Oven:
Dryer
.... .
Outdoor BBQ:
Other:
TOTAL OUTLETS
FORM C C:\Documents and Settings%jorback\Desktop\Form C.doc Updated: 10/2010