20160719082631.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):
Parcel #:
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Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT:
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Phone: Fax:
Address (Street, City, State, Zip)„
E, -Mail Address � I\
PROPERTY OW ER:(r+�_
one:, Fax:
Address (Street, City, State, Zip);
E -Mail Address: h
Scti -ti5
TDING AGEN
Phone: Fax:
At,l" s (Street, City, State, Zip).
E -Mail Address:
CONTRACTOW"
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 TANK
DEMOLITION
DETAIL THE SCOPE OF WORK N..._�'`}`�.. -.......
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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: Owner Agent/Other ❑ (specify):
... � . _ Date _. .......- .n
_. ..-- _..
FORM C L:\Building New Folder 201 HONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
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PLUMBING
Fixture Type (new and relocated)
Total #
FIXTURE COUNT
Fixture Type (new and relocated) Total #
Water Closet (Toilet)
Furnace
Pressure Reduction Valve/Pressure Regulator
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
BTUs: Location(s):...,,,,,,,.
Water Service Line
Tub/Shower
#m CFM: <lOk� >lOkLocation(s).....
Drinking Fountain
Dishwasher
Clothes Washer
Hose Bib
/ Compressorer / Heat Pump /
0o'
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
__-.-----._-_--------
Water Heater Tankless? Yes ❑ NoF_1
..-W__
- ..-w.-.. ..........
Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink
3-15, 15-30 Location(s) ....
Other:
Refrigerator water supply (for water/ice dispenser)
Other:.
Other: L_
I
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #-LElec #t7t11eY':,
#_BTUs: <100k 1 >100k_ Location(s)
BTUs: Location(s):...,,,,,,,.
Air Handler / VAV
Gas # Elec #,,uaw-vOther:
#m CFM: <lOk� >lOkLocation(s).....
(circle selected)
_ AwAA ,
Water Heater
/ Compressorer / Heat Pump /
0o'
Gas #LElec #_Other:
, # BTUs: ............<100k,V1 100k -500k, ..500k-1Mil
..-W__
Roof Top Unit
HP; <3, ....................
3-15, 15-30 Location(s) ....
(circle selected)
Other:.
..,,_
BTUs: �.....� Location(s):....., ....... -_. mw. ��.�.........
Hydronic Heating
Gas # Elec #_In
-Floor _Wall Radiant_ Boiler BTUs: Location---_
Exhaust Fans (single
Bath # #,_www Laundry # � 04her: ,,,,....... _........... _#.,m ._
duct)
,_µµ.,._.Kitchen
,m
Fireplace
Gas #�Wec it
Other,..- � #
Dryer Duct
Outdoor BBQ
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s):...,,,,,,,.
�...
Furnace
BTUs:-...�.a_........._... .............
Water Heater
BTUs Location(s): _ .....------
..-W__
Boiler
..
BTUs:�... ..._�. Location(s), .�._�. ......
Other:.
..,,_
BTUs: �.....� Location(s):....., ....... -_. mw. ��.�.........
.................
Fireplace/Insert
— . _..._---
BTUs Location(s)-,
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\DONE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014