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DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
7`s t 121 5`h Avenue N, Edmonds, WA 98020
l 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, Suite #, City State, Zip):
Parcel #:
Y 3 It 1A f N St �Qc.In e?7d S Gc�r4.. ?,TO zo
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
A .ICANT.
Do,614-,r
Phone: Fax:
A( es`8treet, ("� f�t0.e��);; � w�
E -Mail Address:
PROP "l'Y C)''M NIS RI
Phone. Fax:
Address (Street, City, State, Zip):
E -Mail Address:
IIINDINp AGENCY:
Phone: Fax:
r ss (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
in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
PLUMBING MECHANICAL L I TANKI
I DEMOLITION
SCOPE OF WORK:......
`
DETAIL THE
_„____.. - ......__.
_.. ..... .... .............
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 �T e <�. Owner alW:gent/Other
❑ (specify):
Signature: JA�...' �W____ .ww. _ Date: ,_Z�' l6
FORM C L:\Building New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014
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