20160707104931.pdfDEVELOPMENT 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): d
17� Ila O �• "'t / c ?a 0.;,d
Parcel #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT:_
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Phone: Fax:
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A
.—17%,
Addn�s (Street, Cit , State, Zi ):
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E -Mail ddve
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,� r ,is,r O I>�[i7 I
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PROPERTY OWNER: // 4/Phone:
"< !o !/✓fid A
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Fax;
Address (Street, City, State, Zip):
1"'-"ia1 Aclai ress:
LENDING AGENCY:
Phone: Fax:
O�
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*ye.
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Phone. Fax:
Address (Street, City, State, Zip): V
E -Mail Address:
WA St 1&fMrxp,
1�ta�� License Date:
*Contractor must have a valid City of Edmonds business license prior to doing work'M
in the City. Contact the City Clerk's Office at 425.775.2525
City Business License Ilytixii, Date:
PLUMBING MECHANICAL TANKI
I DEMOLITION
DETAIL THE SCOPE OF WORK; ..e,r�' 1–�(r P„r .
—
.......r........./ -- J i10 -00&7r ....... _.......
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 Owner X Agent/Other (specify): u
Signature: _.� _. Date: .
FORM C L:\Building New Folder 2010\DONE & x-ferred to L -Building -New driveTorm C 2014.docx Updated: 1/17/2014
PLUMBING
FIXTURE COUNT
MECHANICAL
Appliance/Equipment Information (new and relocated)
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
Total #
Water Closet Toilet
(Toilet)
Location(s)__
Reduction Valve/Pressure Regulator
Pressure Redu„
.. _—..........
Air Handler / VAV
Sink (kitchen laundry lavatory, bar, eye wash, etc.)
w------�
#_Other:
.......,m.. __ ....
Water Service Line
Locations)
_
Tub/Shower
(circle selected)
Drinking Fountain
Dishwasher
Clothes Washer
w -__�_...
W ........ .. ....
Hose Bib _-� uw_r....
Other:.msuNu_
.._ ...,.�..-.,,,,. _________
Backflow PreventionDe VICe (e.g. RBPA, DCDA, AVB)
BTUs:
Water Heater Tankless? Yes ❑ NoVLJ
Boiler / H a /
Heat Pump
Hydronic Heat in: Floor E]Wall ❑
Elec # ,�.
Floor Drain/Floor Sink
100k -500k, _ ........ ,..500k-lMil
Other:
Roof Top Unit
Refrigerator water supply (tor water/ice dispenser)
<3,
Other:
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #,_
_,Elec #—Otht.r:
............ #–,--, BTUs: <100k— >100k,_,,,,,,,,,,,,
Location(s)__
j
Air Handler / VAV
Gas #_Elec
#_Other:
#_CFM: <lOk >lOk_
Locations)
(circle selected)
,,-�.... Location(s): ,,_ ,,,,,,,,
Boiler
BTUs: _
AC / Compressor /
Other:.msuNu_
BTUs:
Boiler / H a /
Heat Pump
Gas # ...._,
Elec # ,�.
tier. _— _________ BTUs:_....................<100k,
100k -500k, _ ........ ,..500k-lMil
Roof Top Unit
HP:
<3,
3-15 15-30 Location(s)
Dryer
(circle selected)
Outdoor BBQ
Hydronic Heating
Gas #_Elec
#
In -Floor. ... ........... Wall Radiant....."", Boiler BTUs:---Location,,,,,,,,,,,,,,----
TUs:_JLocation,,,,,,,,,,,,,,,,,,,,,,,,--,,mExhaust
TOTAL OUTLETS
ExhaustFans (single
Bath #
Kitchen #_Laundry # Other: .............
duct)
Fireplace
Gas #, �
Elee # -----011ier
........ ...... #— Location(s)
,, ,,...__ ,m„ _
Dryer Duct
11
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs.,,,,
.��---
Location(s)
.---------�
Furnace
BTUs:
.,, Location(s):
Water Heater
BTUs: _
,,-�.... Location(s): ,,_ ,,,,,,,,
Boiler
BTUs: _
Location(s)::
Other:.msuNu_
BTUs:
Fireplace/Insert
BTUs:
_ Location(s):,. -...-� w
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C 1-Muilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014