20160907114200.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`1' Avenue N, Edmonds, WA 98020
Phone 425,771.0220 `t 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
AP'I I , N . °v Phone: Fax:
360 02
S ate, Zi E-Mail Address„
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PROIa, V,I ' OWNER: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address.
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
, 1t7 , _ Fax:
CtIN 1"IIA . " N. (ill t C 6 C
Address Str
eet, t, Ctt „ State, Zip): E-Mail Address:
/ (� t S er �0—,e5
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
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DETAIL THE SCOPE OF WORK A"-.... ��. . "
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...fit .._.�(__.."... m..r ...�..............._ _._ _....
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: _.. ...._ Q�.._ .. ���.._ Owner ❑ Agent/Other ❑ (specify)..... .... .,, w .......____
Signature: Date. _.. .... .......
- -
FORM C 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 (Kitch.e-.n laundry, lavatory, bar, eye wash etc) � Water Service Line
�� ..
Tub/Shower Drinking Fountain
...._._._........ -w....,,,,...................,........._.......
Dishwasher Clothes Washer
_. ...w w m _w ------------
Hose Bib 2 Backflow Prevention Device (e.g. xBPA, DCDA, AVB)
Water Heater Tankless? Yes ❑ Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink Other:
__................... . ..... .......................
Refrigerator water supply (for water/ice dispenser) Other:
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas # mm_Elec
(,)tlze t:,_.....--.....__.W_... _
#_ ...„Nq BTUs: <100k--..„>100k__
Location(s)
Air Handler / VAV
Gas #.
Elec #—Other:
# CFM: <10k_, >10k_
Location(s).___
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Gas k.—Elec
#,
Other:
# BTUs: <100k,
100k-500k, 500k-1Mil
Roof Top Unit
HP:
<3, ..... _,
_3-15, „ .............. _15-30
Location(s)
(circle selected)
Hydronic Heating
Gas #„µ,mmmmm
Elec #,.,.,,_.In
-Floor ..........Wall Radiant„mm m� Boiler BTUs:-.,,,,,-,
Location,...............................................................................
Exhaust Fans (single
Bath #
Kitchen #_Laundry #
(Itth�t
it
duct)
------....
,, ,,,,,� Pwww ---
Fireplace
Gas #
Elec # —
_Other :................................................
# Location(s)...............
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs.
-- . Location(s);................ ..... ........_...--..
Furnace
BTUs: ,,,,,,
Location(s): _ �,,,,,,,,
Water Heater
BTUs: �_
_. _w Location(s): wmw dada-..._ ......... .... ............................ ... ._.........._.
Boiler
BTUs:,,,,,,,,
Location(s):,_,m,,.._
Other:.,,,,,,,,,
BTUs:
�. Location(s):_-..... ...- --- ........._._......_. ,,,,,,.., m,,.................
Fireplace/Insert
BTUs:
Locations :,
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