20160718112333.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`" Avenue N, Edmonds, WA 98020
est• 1 w Phone 425.771.0220 It 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 #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes�'No ❑
APPLICANT: —
Phone: Fax:
Address (Street, lwoty, Stat
, t e, Z"lip„ jj
E -Mail Address:
PROPER O'p4^'NEX:
"
Phone: Fax:
Address (Street., City, Str:t , Z')):
E -Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:.
CONTRACTOR: *
Phone: Fax:
Ad( fess, (Street, City, gal:tte„ Z p}:ll Address.,
y .
WA State License #/Exp, Date:
*Contractor must have a valid City of Edmonds business license prior to doing work 71— 'w
in the City. Contact the City Clerk's Office at 425.775.2525
City Business, License #/Exp. Date:
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK
N...1 j_..
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: .-.-..,. � �..���.�.����� ..n�.
Owner A ent/Other ❑ (specify):
g P Y): ..,�._.� ...-_m ............-..
Signature: _... — ..... �,.�
Date;
FORM O L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014,docx 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
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Water Service Line
Tub/Shower Drinking Fountain
�..w .�... _ m.
Dishwasher Clothes Washer
_.�, _.. ...._.-.....-...., ......
Hose Bib Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
..............
Water HeaterTankless? Yes ❑ No Hydronic Heat in: Floor ❑ Wall ❑
._......... —
Floor Drain/Floor Sink Other:
...
Refrigerator water supply (for water/ice dispenser) Other:
MECHANICAL
Equipment Type Appliance/Equipment Information (new and relocated) Total #
Furnace I Gas #Elec #t ..__,_Otber:,w #_ BTUs: <100k_ >100k Location(s)
Air Handler / VAV
Gas #_Elec # Other: # CFM: <10k >10k Location(s)w_
(circle selected)
AC /Compressor /
Boiler / Heat Pump /
Gas # _ Elec ##„_._at 191aer: _ # BTUs: ____ _________<100k, 100k -500k, 500k-1Mil
Roof Top Unit
<3, 3-15, 15-30 Location s) ��...............�............_�......._......... ...e.w... ..w� .®
HP:(
(circle selected)
Hydronic Heating
Gas #_Elec #_In-FloorWall Radiant., „ Boiler BTUs:-------------- _ L.ocu lon
Exhaust Fans (single
Bath #_ Kitchen # Laundry # # _.
..
duct)
Fireplace 1I Gas #_Elec #_Other:.______ ---------- __ #__ Location(s)
Dryer Duct
FORMIC L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014