20160420113116.pdfit
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5'" Avenue N, Edmonds, WA 98020
st. Phone 425.771.0220 4 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): I -F e°�.,
Parcel #:
rr o ca '2_ t c3 0
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT:
Phone: Fax:
0-56(9°C)Iriac
Address ("street, City, State„ ..ip):
E -Mail Address:
PROPERTY OWNER:
Phone: Fax:
Address (Sire+et, City, Skate„ 'Zip): Ce t, 2
E -Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*
Phone: Fax:
L+. L q
Address (Street, City, State, Zip): zi El 2.190
E -Mail Address:
V1 CJ A
WA State License #/Exp. Date: '6 , ®ry
*Contractor must have a valid City of Edmonds business license prior to doing work
KA1V" E C 2 ;
in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
PILI, MBING MECHANICAL TANK
DEMOLITI'O'N
DETAIL THE SCOPE OF WORK: n_
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 Agent/Other (specify): _ . M .�
w
Signature: �r ��, Date: �_ °
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