20160914093152.pdfy DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5"' Avenue N, Edmonds, WA 98020
Phone 425.771.0220 R 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 #:
10, 5'L v
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT?
Associated Permit #:
Yes ❑ No
APPLICANT:
✓i��e ���w\� �t�
Phone: Fax:
°�-Seo-Ry�7 ZOt,-L(�-I-7
Address (Street, City, State, Zip):
® lC 7-'13'5
E -Mail Address: I /
r! 2S (7:11 l7ictvlc5 TG- a4 (k- tl (ok)
_
PROPERTY OWNER:
I�av�.� ���r
Phone: Fax:
m�n
Address (Street, City, State, Zip):
k -1 r ( T& I� �— c
h E -Mail Address:
LENDING AGENCY: _ _�
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*r,� I
i)I[k� � �'N1ou�
Phone: Fax:
-z (, S -
Adch (Street, City, State, Zip):
�-Y?
E -Mail Address:
(- s'ct 1-�
WA State License #/Exp. Date:
��Citrho ►,
* Contractor must have a valid y of Edinonds business license prior to doing work %� o Gt h� i ✓ Dl t C -
in the City. Contact the City Clerk's Office at 425,775.2525
City Business License #/Exp. Date:
000533 i%K
WIRMITAPPLICATION
PLUMBING MECHANICAL
FOR:
TANK DEMOLITION
DETAIL THE SCOPE OF WORK. _ ° u a w
tf c o f o ✓tt
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.
r
❑ E6
Print Name ' c Owner
Agent/Other (s ecif
Date:
Signature: (�_..... .. ....... _ ....._. ...........
FORM C L:\6uilding New Folder 2010\DONE; & x -ferrel to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
w.. ... _. ........ _........�__.. M
Fill in Place Fill Material_____'__ ......,, Fill in Place Fill Material
.....
Removal Removal
Number of Gallons 5fl� .dam _ Number of Gallons:
Critical Areas Determination: Study Required conditional. _... �.
Waiver El WaiverEl
(-VAtt u to -000
FORM C L:\Building New Folder 2010\DONE & x-fer ed to L -Building -New drive\Form C 2014.doex Updated: 1/17/2014
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