20160429100547.pdffA 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
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
Associated Permit#:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
AP11 PL11 ICANT:Phone: Fax:
Coy L i q{ .S- -I S-0
Address (Street, City, State, Zip): 1 E -Mail Address:
'5aM-e_ 61-S �� D �
PROPERTY OWNER: Ch o f 1�11/_ Phone: Fax:
Address (Street, City, State, Zip):
Ce
Ol Atltlra ssw .m)
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* Lt,')Ll _ o Phone: Fax:
Addr11 ess (Street, City, State, Zip): E -Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date„
wI,111MI31NCr MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK:. — _.�.. ............. _ _.. ..........
OL
.
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. mmm r�C _� Owner %A ent/Other ❑ (specify):
Print Name Date: g -w.-........�.,. _...�
Signature. _. �._—�....... �,�Nw�... ....e __... ..- ..
FORM C L:\Building New Folder 2010\130NE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
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PLUMBING
Fixture Type (new and relocated)
FIXTURE COUNT
Total # Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
Pressure Reduction Valve/Pressure Regulator
AC Unit
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Water Service Line
Location(s):...._ .m. ..........
Tub/Shower
Drinking Fountain
Total #
Dishwasher
Clothes Washer
#,_„µ_,Other:_,--_
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Location(s)
............. ......
Water Heater Tankless? Yes ❑ No ❑
_vv__µ W _ _ _...-----�
Hydronic Heat in: Floor ❑ Wall ❑
Gas #_Elec
Floor Drain/Floor Sink
Other:
#„w,,,,,,,,,,,,,,,,, CFM: <lOk„m,m,m,m,m,m >lOkmm,m,
...............................................................
Refrigerator water supply (for water/ice dispenser)
Other:
(circle selected)
Appliance Type
MECHANICAL
Total #
AC Unit
Equipment Type
Location(s):...._ .m. ..........
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #.--Elec
#,_„µ_,Other:_,--_
__-- _---
#,, m,,,,, BTUs: <100k-- , >100k
Location(s)
Location(s):_.__,,
Air Handler / VAV
Gas #_Elec
#_Other:
BTUs:�,
#„w,,,,,,,,,,,,,,,,, CFM: <lOk„m,m,m,m,m,m >lOkmm,m,
.
Locatton(s)�„
....
Other. _.....
(circle selected)
...
BTUs: _---.1
...... ___,m Location(s):._,,,,,,,,,,,
.
_
.
.
BTUs:,—.—,,,,,,
AC / Compressor /
Stove/Range/Oven
Boiler / Heat Pump /
Gas #
Elec #_Other:„,
.—.—,,,www„
# BTUs: <100k,
100k -500k, 500k-1Mil
Roof Top Unit
HP: ..............................
<3,-3-15
. ....... ........15-30
Location(s)
TOTAL OUTLETS
(circle selected)
Hydronic Heating
Gas #„_mm
„Elec #,
In -Floor Wall Radiant--- Boiler BTUs:.—.. ---,m_,,,,,
Location—
ocation,,,,,,,Exhaust
ExhaustFans (single
Bath #_
Kitchen # Laundry #._
Other:.
duct)
I
Fireplace
Gas #,mmmmmm_Elec
k—
Other: .........
)4 ........ Location(s)._,,_,,,,_
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: .._
Location(s):...._ .m. ..........
Furnace
BTUs:
...._. Location(s): —........
ater Heater
BTUs: „„
Location(s):_.__,,
Boiler
BTUs:�,
,,...._.. Location(s):� _. ........_A -
....
Other. _.....
...
BTUs: _---.1
...... ___,m Location(s):._,,,,,,,,,,,
--.... ...__..__
Fireplace/Insert
.
.
BTUs:,—.—,,,,,,
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LA13uiWing New Folder 2010\DONE & x -ferrel to L -Building -New drive\Form C 2014.doex Updated: 1/17/2014