20160510113413.pdfa DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
S1 tl ' Phone 425.771.0220 ft Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Su #, City State, Zip : Parcel #:
Sqa� Sr Isbi
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No rlupLP
APPLICANT: 1i� co Phone: Fax:
Cit.
PROPERTY WN
Aa1 X11 ti�St�k�t, Cit 'taste" ).
57--51 . 51
LENDING AGENCY:
Address (Street, City, State, Zip):
CONTRACTOR:* —V_
116
Address'Strcct.1City, Starts„ !i }i
�t Ik E -Mail Address:
l9/ Phone:
/4 E -Mail Address:
Phone:
E -Mail Address:
*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
PLUMBING I MECHANICAL TANK
DETAIL THE SCOPE OF WORK _ .
.....
/s'�
Fax:
Phonc; Fax:
E M, ii AddrL ss:
W'A S arte "Well se #C 7 x
City lir;irrr as LicenseItil"
m - p9l"t
DEMOLITION
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. ��qq
Print iarmc, �. ,. .... ......m.m. Owner LL`J A c,110.iI'll
aer° (specify): ,.
Signature.. Date: ,_ .. ... ...._
.wr........�
FORM C LABuilding New Folder 2010\DONE & x-ferred to L Building -New driveTorm C 2014.docx Updated: 1/17/2014
PLUMBING FIXTtJRE COUNT
Fixture Type (new and relocated) Total # Fixture Type (new and relocated) Total #
Water Closet (Toilet) Pressure Reduction Valve/Pressure Regulator
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.) Water Service Line
Tub/Shower Drinking Fountain
Dishwasher Clothes Washer
Hose Bib Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless?Yes ❑ No ❑ Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink Other:
Refrigerator water supply (for water/ice dispenser) Other:
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #
Elec #_Other:,—,,,
-www , # BTUs: <100k >100k_
Location(s), _ ........ ....
Air Handler / VA V
Gas #
Elec #_Other:—,.
#_CFM: <10k_ >10k_
Location(s)__ �,
""�
(circle selected)
Water Heater
_
�,H
AC / Compressor /
._............. -
Boiler
BTUs:w.._..._
.. Location(s):_---- ......
Boiler / Heat Pump /
Gas #_Elec
#Other:
................................. # BTUs: <100k,
100k -500k, 500k-1Mil
Roof Top Unit
HP:
<3, _-rew-J-15,
m...15-30 Location(s)
_ ........ ......
(circle selected)
............, m„
Stove/Range/Oven
�_
_.. �..... ..
_ ......�..,, ... .-..... ., �............. _
........
Hydronic Heating
Gas #...................
Elec #_In
-Floor _Wall Radiant ....... Boiler BTUs:
Location„ _ ww ......m.
Exhaust Fans (single
Bath #--------Kitchen
# Laundry # a_ .........
_r_...ma...W-..... -- #...m.........
duct)
� _Otltt.t•:
Fireplace
Gas #_Elec
#_Other:
....... ....... #_ Locattion(s)_..._.....
6 ..._ ...............�
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs ....
.....
www-- _ Location(s): �.... .. �........- .....
..
Furnace
BTUs __
_...Location(s):�_..wm......... .....�... ____...____
Water Heater
BTUs:
_ Location(s):.... ..
._............. -
Boiler
BTUs:w.._..._
.. Location(s):_---- ......
Other: _ m
BTUs:Location(s)w�.-�.�............
,,,.m-_� _..
Fireplace/Insert
_
BTUs:.......,�.
_ ........ ......
_....
............, m„
Stove/Range/Oven
�_
_.. �..... ..
_ ......�..,, ... .-..... ., �............. _
........
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORMC L:\Building New Folder 2010\DONE & x -ferrel to 1 Building -New drive\Form C 2014.docx Updated: 1/17/2014