20160714094420.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
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): C1 � 04C Parcel #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT: Phone: 2 Fax:
Address(Street,CCity, StatZP). E -Mail Address:
10 11 y �u P � 0• 1
CO+v\
PROPERTY OWNER: Phone: Fax:;
Address (Street, City, State, Zip): E -Mail Address:.
LENDING AGENCY: Phone: Fax;
Address (Street, City, State, Zip); E -Mail Address;.
CONTRACTOR:*:3 _ i Ll. C �n��� pj�i(�� Phone: F=
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 Laeell�l xia. 1)�c:
PERMIT APPLICATION FOR:
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK . .......-Z_.......�-ta�t._�A0.............. t �..._...�"�
.....��Ct.It.,�
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 aA!ent of the property owner to submit a permit application to the City of
Edmonds. pp
Print Name:��. t".:�.L ....... Owner Agent/Other(specify) ,4�.��"�"4.._t'....._
Signature: .... . ..... u.. _ M "�mn_ .—. Date: 3 71171__ i9
FORM C L:ABuilding New Folder 201tiAR':30N)Z-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)
..... Location(s)
Pressure Reduction Valve/Pressure Regulator
Air Handler / VAV
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Elec #
Water Service Line
Location(s),_,,
.................. _
Tub/Shower
(circle selected)
......................... m - ........
Drinking Fountain
Dishwasher
,,n_m,
Clothes Washer
AC / Compressor /
-Hose Bib .......... ...,,,,............ .� �.. �.._�.�,.
Other _...... ..........m_ --_ w
Backflow Prevention Device (e.g. KBPA, DCDA, Ave)
BTUs: �..
........ ........-
Water Heater Tankless? Yes [:]No
__
........... _._.....
Hydronic Heat in: Floor ❑ Wall ❑
#
-.................. _--
Floor Drain/Floor Sink
100k -500k, ,..........500k-1Mil
Other:
Roof Top Unit
Refrigerator water supply (for water/ice dispenser)
---------<3 . .............3-15,
Other:.
m....m..._ ..........
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #
Elec #_Other:
,,,_ #,W,—,,, BTUs: <100k,_- >100k_
..... Location(s)
-.............
Furnace
Air Handler / VAV
Gas #
Elec #
Other: # CFM: <10k >10k_
Location(s),_,,
(circle selected)
_a _, Location(s): d_e_e.e..
..
Boiler
,,n_m,
BTUs: -_-------
AC / Compressor /
Other _...... ..........m_ --_ w
BTUs: �..
.-._.�...ti—Location(s)......e. _
Boiler / Heat Pump /
Gas #_Elec
#
Other_________________________ .... # BTUs:__ ................. _ „_...
100k -500k, ,..........500k-1Mil
Roof Top Unit
HP: ...—
---------<3 . .............3-15,
15-30 Location(s) ,_ ,,._-----
m....m..._ ..........
Dryer
(circle selected)
Outdoor BBQ
Hydronic Heating
Gas #................
Elec Fl ..................
In -Floor _Wall Radiant ......... Boiler BTUs: ...............
— Location
TOTAL OUTLETS
Exhaust Fans (single
Bath #
#_Laundry # _ Other:-
... ...-.�.. ...__—#�...s.
duct)
_..............Kitchen
Fireplace
Gas #
Elec #_Other:
#_ Localion(s)_.
,,, ,___ �--..m.....
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:.. ...............
�� _.Location(s)r............_�
-.............
Furnace
BTUs: _
_wu.. Location (s). �,.........__
Water Heater
BTUs:
_a _, Location(s): d_e_e.e..
..
Boiler
BTUs: -_-------
�:
._ Location s __.,
Other _...... ..........m_ --_ w
BTUs: �..
.-._.�...ti—Location(s)......e. _
Fireplace/Insert
BTUs: wm
....._. Location(s)m.�._.......
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C U\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014