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20160805133314.pdform DEVELOPMENT SERVICES PLUMBING, MECHANICAL, TANK, & DEMOLITION PERMIT APPLICATION 121 5 x Avenue N, Edmonds, WA 98020 t• 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 #: s P_ �- o o Z 0_51 20 oa Associated Permit #: IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑ APPLICANT: �T y7 U Me t N_t— �(I e. 425,Z`� 60 Fax: may, Address (Street, State, Zip): p E -Mail Address ©� PROPERTY OWNER: A_ , 1 -V all i Phone: Fax: Address (Streeet, Cit , Statteee Zip): E-Mail Address: LENDING AGENCY: Phone: Fax: Address (Street, City, State, Zip): E-Mail Address: CONTRACTOR: Phone: Fax: Address City, te, Z. ): E-Mail Address: f�(Street, St WA State Licensc#llixp. Date: w. " ° Zs'4� ` *Contractor must have a valid City of Edmonds business license prior to doing work 1 Li& in the City. Contact the City Clerk's Office at 425.775.2525 City Rusinoss License #/Exp. Date: PLUMBING MECHANICAL TANK Dls'MOLITION DETAIL THE SCOPE OF WORK:.. ••............ .. �..._... ��.1 ..�,�..._ :.:_..... .. __. ..... �......_ 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. • ��—y ge(specify): Print Name: j„„ �..', " .,.._-- Owner V_9 Ji runt101htr � •,,.m" Signature:. .. . `� � :........ ... Date: e�� �� .... .... FORM C UTuilding New Folder 2010\DONE & x-fened to L-Building-New driveTorm C 2014.docx Updated: 1/17/2014