20160422090309.pdfCity of Edmonds
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A Fax 425.771.0221
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
H M `
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No FX
APPLICANT: Phone: Fax,
C-,:) , 'y' CA—' A, 1
Address Street, (.1ty, State 7"ll� l: E -Mail Address:
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PROPH`RIIN OWNL II Phone: m a Fax.
(Street, City, State, Zip): E -Mail • dda ess.
Address
S s� 1Q C c� w5 1Q 1 F�w1 c
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LENDING AGENCY, Phone: Fax:
Address (Street, City, State, Zip)., E -Mail Address:.
CONTRACTOR:*Phone: I - z ; f
Address �,,;"tw ec, C"it ,
State, Zi ): E -Mail Address:
WA State Irla a tl, x #/ �x ): Date:
*Contractor must have a valid City of Edmonds business license prior to doing work ;,, 1
in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
PLUMBING MECHANICAL _6TANK tj DEMOLITION
DETAIL THE SCOPE OF WORK: . .... .. t m t . � .. e -y Vl q--
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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.
_r ` .. �.... � Owner ®Agent/Other (specify): ��.�. � `�,��
Print Name: .j
Signature: "a i( ie.� Date: 1 —� '(do -
FORM C L:\Building New Folder 2010\130NE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
PLUMBING
Fixture Type (new and relocated)
Total #
FIXTURE COUNT
Fixture Type (new and relocated)
Total #
Water Cee( (Toilet)
Gas #_Elec
ReductionValve/Pressure Regulator
....._.._-..._..,., # BTUs: <100k >100k_
Sink (kitchn+ laundry, lavatorY+ bar, eye wash etc.)
Air Handler / VAV
Water Service Line
#,�
Tub/Shower
Location(s)_,,,,.. ........___..-.
Drinking Fountain
...__
Water Heater
Dishwasher
_. .................#_CFM: .................. ..................
Clothes Washer
AC / Compressor /
................ ........_-.........,,,,,
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
.... Location(s)-,_m......
Water Heater Tankless? Yes ❑ No ❑
Gas #_...._„Elec
Wvvv___ ......
Hydronic Heat in: Floor ❑ Wall ❑
t)ther: # BTUs: <100k,
Floor Drain/Floor Sink
Roof Top Unit
Other:
Refrigerator water supply (for water/ice dispenser)
........�.�.�.�.�.�.�.�.�.�.�.....�..__ ,,,
Other:
Stove/Range/Oven
Equipment Type
----------------
MECHANICAL
Appliance/Equipment Information (new and relocated) Total #
Furnace
Gas #_Elec
#_t)tltat°:,
....._.._-..._..,., # BTUs: <100k >100k_
Location(s) ,J
Air Handler / VAV
Gas #_Elec
#,�
()t1 cr: <10k >10k
Location(s)_,,,,.. ........___..-.
(circle selected)
...__
Water Heater
.........
_. .................#_CFM: .................. ..................
Location(s):___,�....
AC / Compressor /
Boiler
BTUs:..
.... Location(s)-,_m......
Boiler / Heat Pump /
Gas #_...._„Elec
#,
t)ther: # BTUs: <100k,
100k -500k, ..... _500k-1Mil
Roof Top Unit
HP: ._ ......................<3,
3-15, 15-30 Location(s)............................................
........�.�.�.�.�.�.�.�.�.�.�.....�..__ ,,,
(circle selected)
Stove/Range/Oven
Hydronic Heating
Gas #_Elec
#_In
-Floor _Wall Radiant .................. Boiler BTUs: ................... _.........
__.._ Location,,,
Exhaust Fans (single
Bath #_Kitchen
# Laundry # ----."Alter-. �
_..............__ #mw
duct)
TOTAL OUTLETS
Fireplace
Gas #_Elec
#_Other:
#_ Location(s)„_,_
. ............... ,,,.._
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: .w-,�w_.._.....
Location(s):.....m..-.__ ... .n.�--- -----
Furnace
-BTUs:
Location(s): „ ,,,,._----,. .......
...__
Water Heater
.........
BTUs:��...v
Location(s):___,�....
Boiler
BTUs:..
.... Location(s)-,_m......
-
Other: _...--..._
BTUs:.
.....
_ -._.. Locations):,,,
Fireplace/insert
BTUs:
Location(s):_. _....�,w .....-.._A _ .
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.doex Updated: 1/17/2014