20160616.pdf.4
City of Edmonds
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`" Avenue N, Edmonds, WA 98020
Phone 425.771.02201t Fax 425.771.0221
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.41-
APPLICANT,
I Inc
Phone: �
F'ax:
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Fax:
t1dl'ess "street „ ��it ,�tc�,
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E Mai] Address:
LENDING AG�NC:
Phone:
Fax:
Address eet, City, State, Zip):i
E-Mail Address-
CONTRACTOR-*
Phone:
Fa11 x11 :
Address (Stream, Ci" ,„ ,S.tate Zip): t
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
DETAIL THE SCOPE OF WORK:
MECHANICAL I I TANK
WA State License #/Exp. Date:
City Business License #/ExpIIII..�IIIIIIIIIIIIIDate:
DEMOIo TION
n -v J 1/1
]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 ❑ A gentli,ltlle s eci
i
Signature. .._..w. Date: ��.I.� ._....��..
FORM C LABuilding New Folder 2010\DONB & x-ferred to L-Building-New driveTorm C 2014.docx Updated: 1/17/2014
Fixture Type (new and relocated) Total # Fixture Type (new and relocated) Total #
Water Closet (Toilet) Pressure Reduction Valve/Pressure Regulator
Sink latchen, laundry, lavatory, bar, eye wash etc.) Water (� �', r7 Y Service Line .._...�.
.. .. �...._.... �...._ � � ......
...
Tub/Shower
Drinking Fountain
Dishwasher Clothes Washer
�_......... ....WW............ ......... ..
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:
......
_� ..._... _..._ A..
Refrigerator water supply (for water/ice dispenser) Other:
Equipment Type
Furnace
Air Handler / VAV
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Roof Top Unit
(circle selected)
Hydronic Heating
Exhaust Fans (single
duct)
Fireplace
Dryer Duct
Appliance/Equipment Information (new and relocated)
Gas # Elec # Other: # BTUs: <100k_ >100k_
Gas # Elec # Other: # CFM: <10k_ >lOk_
Gas # Elec # Other: # BTUs: <100k, 1
HP: <3, 3-15, 15-30 Location(s)
Gas #_Elec #_In -Floor _Wall Radiant_ Boiler
Bath #_Kitchen #Laundry # _
Gas # Elec #_Other: #
I,ocatlon
S00k-1Mi1
Total #
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: �www Location(s),�'_
Furnace
BTUs: �........� LocatioiiPP0:.
Water Heater
BTUs: Locati?1n(s)
Boiler
_ _.
BTUs. .. Lot tta n�(s) -_ .... �..
Other: _......
�_...� � .. _ .
STUB. I atioti(s) _IT
Fireplace/Insert
�... ._.
BTUs: ..._... L cation(s)
_
Stove/Range/Oven
....... ..... ....-.......
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 201 HONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/1712014
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New driveTorm C 2014.doex Updated: 1/17/2014
City of Edmonds
PROJECT ADDRESS:
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT CHECKLIST
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 Q Fax 425.771.0221
Plans shall
be of sufficient clarity to indicate the location, nature, and extent
of the work
proposed,
and conform
to the provisions
of
the adopted
International Codes and City Ordinances.
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SUBMITTAL REQUIREMENTS
oPra
The number indicates the number of copies for submittal( ifIt
rn
applicable). Check marks indicate additional submittal
y
.
w
fD
requirements that may apply to your project.
F_
_..... .......... _.. _..�..... .......
Application Form C
1
1
1
1
Site Plan
_.....wm....
3
__......wr.,.,
I
�.........-..
Mechanical Plans
2
Manufacturer's Specifications/Cut Sheets
0
2
2
Elevation View for Roof Mounted Equipment
0
_0
0
2
2
Structural Calculations
✓
-... ..- .. ..
Ylumbin�Plans
.e�....�
.-_..
2
...
Ltsted and Tested Fire Sto in Assemblies
2
.r
Washington State Contractors License
✓
✓
✓
✓
...... ..... .... �. �....
Contractor s City of Edmonds Business License
✓
✓
✓
...
✓
Critical Areas Determination or Checklist
1
✓
�.
�._._. _ . ,.. ,,..m .. ...... �...
State Non -Residential Energy Code compliance forms
...
u..
...... m2
_., ,,..�
A _ ..
• Handouts
and Standard Details may be found on the City's website,CIIIIa1N14,i„„ti.r�
or can be
obtained at
City Hall
during
normal business hours.
• Plans/calculation/reports
prepared by state licensed architects or professional
engineers
must
be stamped
and signed
by the
design
professional.
FORM C LABuilding New Folder 2010\DONE & x-ferred to I. Building -New driveTorm C 2014.docx Updated: 1t17/2014
FIELD NOTES: J�z
JOB COMPLETED BY:.
Site info taken by:
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