20160523144257.pdfmm DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
I t 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):
Parcel #:
413 l tti Av
e
Associated Permit #,
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT: ,
It' /J 1{^L,4
Phone: Fax:
f s-,2 J-P14-2
Address (Street, City, States Zip):
E-Mail Address„
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5 T� r�-7 r-
PROPERTY OWNER: k
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Phone: v7 Fax:
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Address (Street, City, State, Zip):
E-Mail Address
LENDING AGENCY:
Phone: Fax:.
Address (Street, City, State, Zip).
E-Mail Address;
CONTRACTOR:*
Phone: Fax:
Address (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 L _ n- ° ,s if 2 S/
in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
o /3/ 6
PLUMBING MECHANICAL
TANK DEMOLITION
DETAIL THE SCOPE OF WORK aC U d"brG.c.7t
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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.
Print Name ��'°^z
n Other s ecif :
Owner :Aget/ � (P Y)
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Signature: �..,�,
Date: S�2 3��.m.�..w_
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FORM C L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.doex Updated: 1/17/2014
PLUMBING FIXTURE COUNT
Fixture Type (new and relocated) Total # Fixture Type (new and relocated) Total #
Water Closet (Toilet) Pressure Reduction Valve/Pressure Regulator
____........ -.... - __I--_____ ..._ -.. __ -_ ....—",w....-_......------ —
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 Appliance/Equipment Information (new and relocated) Total #
Furnace
Gas #_Elec
#_Other:
#_ BTUs: <100k_ >100k_
Location(s)
Air Handler / VAV
Gas #_Elec
#_Other:
#CFM: <lOk_ >lOk_
............................... _.
Location(s)._,,,,,,,—
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Gas #..................Elec
#_Other:
...........................................
..............,. # BTUs: <100k,
100k-500k,.......... ....................... 500k-1Mil
Roof Top Unit
HP:
<3,...............
.............. 3-15.............. ...
...... ._.15-30 Location(s) _ ......
(circle selected)
Hydronic Heating
Gas # .......
Elec #
.........In -Floor
_Wall Radiant_ Boiler BTUs:
Location
Exhaust Fans (single
Bath #------_._Kitchen
#_Laundry #_--Other: . __„.....................
.....
duct)
Fireplace l Gas #Elec #_Other: --- - #_ Location(s)
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: -
m,.... Locations):.-�-- ........ _ .... ... _ -. �
.-- .....
Furnace
....
BTUs:.
_............ Location(s):__ . ....... . ..
........
Water Heater
BTUs: w-
...... _..... Location(s): --.......__..._. ....-_. _................
._..... _..
Boiler
BTUs:........
. _ Location(s):_._ .. �.. ................... �,,..., .
Other: .
BTUs:
_... _- ..W-...- .......
Fireplace/Insert
BTUs:
_,. ... , Location(s):, ........
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
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FORM C 1-Muilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014