20160718141113.pdf41 ,
} DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
ro PERMIT APPLICATION
121 5h Avenue N, Edmonds, WA 98020
S t. Phone 425.771.0220 2 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 #:
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Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICAN�'j I ROC 11"1 `IT ICA-I� C�G.t.0 ,4S V
Ph T1^�y Fax:
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Addres (tr jt', ty, State Zip)
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E -Mail Ad4ress:
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PROPER lO NEY
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Address (Street, City, State, Zip)
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LENDING AGENCY: ,
Phone:
Fax:
Address (Street, City, State, Zip):
E -Mail Address:
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CONTRACTOR:* f1
Phone: AA X_ ax:
Address (Street, City, State, Zip):
E -Mail Address:
WA State 1Wic se #/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 Buts License #/Exp. Date:
PLUMBING MECHANICAL I I TANK'DEMOLITION
DETAIL THE SCOPE OF WORK: crit
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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: �� + ' caner Agent/Other ❑ (specify):
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Signature: _.. a bale:
FORM C LABuilding New Folder 2010\DONE & x-ferred to L Building -New drive\Form C 2014.docx
Updated: 1/17/2014