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DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 51" Avenue N, Edmonds, WA 98020
C st tf 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):
Parcel #:
Au (
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
Associated Permit #:
APPLICANT:Phone:
Fax:
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.2. , �.OLZ
Address (Sfr et, ffy, State, Zip'°
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E -Mail Address„
PROPERTY OWNER:
Phone: Fax:
Address (Street, City, State, Zip)„ �
E -Mail Address:
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LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CON "RAC I'OR:*�
Phone: Fax.
Address (Street, City, State, Zip}: M
E -Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
�p -I � 0
in the City. Contact the City Clerk's Office at 425.775.2525
City I a s" ss Date:
PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK ., ..... .�.:...7.�1�` .. 1. �P �........
at ........_
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: ._,.� _. m -�_. Z.... . Owner ❑ A ent/Other ❑ (specify):. .. ..... ���� ...,
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Date:
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FORM C L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
FE I PLUMBING
Gas # _Elec
FIXTURE COUNT
..._...mee..,
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
#_Other:
Pressure Reduction Valve/Pressure Regulator
#_CFM: <101c >lOk
i .chen___un
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Location(s):___n,,,_..
Water Service Line
. ......_-... __
Boiler
..._Tub/Shower
BTUs:
Drinking Fountain
Dishwasher
._
Clothes Washer
l taatirttt(b,l:.e.... ........
Hose .. _
Bib
Fireplace/Insert
Backflow Prevention Device (e.g. RePA, DCDA, Ave)
BTUs:... .. ...,_�..e_
Water Heater Tankless? Yes ❑ No ❑
Gas #Elec
Hydronic Heat in: Floor ❑ Wall 0
Floor Drain/Floor Sink
100k -500k, 500k-1Mil
Other:
Roof Top Unit
Refrigerator water supply (for water/ice dispenser)
<3, ___3
Other:
.....15-30 Location(s)
MECHANICAL
Equipment Type Appliance/Equipment Information (new and relocated) Total #
Furnace
Gas # _Elec
#,,-._„Other
..._...mee..,
#--------. BTUs: <100k.____ >100k
Location(s),_,,...... ..
Air Handler / VAV
Gas #_Elec
#_Other:
_----�.
Water Heater
#_CFM: <101c >lOk
Locations) ,www,,
Location(s):___n,,,_..
(circle selected)
. ......_-... __
Boiler
BTUs:
—
_.... _..._.... �.
Other:..... _ _
AC / Compressor /
__. ......
BTUs: �. .-- .......-
l taatirttt(b,l:.e.... ........
Fireplace/Insert
BTUs:... .. ...,_�..e_
Boiler / Heat Pump /
Gas #Elec
#_Other:
# BTUs: <100k,
100k -500k, 500k-1Mil
Roof Top Unit
HP:
<3, ___3
45 ...
.....15-30 Location(s)
Outdoor BBQ
(circle selected)
TOTAL OUTLETS
Hydronic Heating
Gas #Elec
#_In
-Floor
_Wall Radiant_ Boiler BTUs:
Location____,__,
Exhaust Fans (single
Bath #_--Kitchen
# Laundry # . �(itlter: „ ,,..........
w ........
duct)
Fireplace I Gas #_Elec #_Other: # l,00dion(ms)
Dryer Duct
Appliance Type Appliance/Equipment Information (new and relocated) Total #
AC Unit
BTUs:......_ ..................... ,... -
Location(s):.w........... ...__.............._._ � � _r�....
Furnace
BTUs:
_ Locatt10n(s):., ._ ....... _ ....... _ �
_----�.
Water Heater
BTUs:
Location(s):___n,,,_..
. ......_-... __
Boiler
BTUs:
Locations):- ....... . . ....__. _......�...
_.... _..._.... �.
Other:..... _ _
__. ......
BTUs: �. .-- .......-
l taatirttt(b,l:.e.... ........
Fireplace/Insert
BTUs:... .. ...,_�..e_
i.acaatitara(")fi...�...A. ..... --- ,m._ _ .
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014