20160920120958.pdfEdf0
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5"' 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 #:
dqo P1ne__ s� Edt-nvyids W A -
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT: I L P S P ll/ih,►) ) � m�b TGI �� �) Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
PROPERTY OWNER:Phone: Fax:
&7 fLf 41 Z -5f3d3 s
Address (Street, City, State, Zip): / / ,� P (A e
Ae E -Mail Address:
LENDING AGENCY: (' I Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* ^„ f''Y (I]� 1n Phone: Fax:
l Y'L
Address (Street, City, State, Zip): E -Mail Address:
WA State License #/Exp. Date:
*Contractor inust have a valid City oj'EdJnonds 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 "ITl„ � In in e'W.....µ Q k (� .... �t
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. / �p�Agent/Other
Print Name: & OwnerLJ ❑ (specify):-.w....w....... _�
Signature: .... _ ...`` _N — w...... 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
–
---- — BTUs: <100k-__w_,>100k,,,,,
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
'
Line
Water Service Ll
l
Tub/Shower
Drinking Fountain
#ww-_www <10k----_ >lOk
Dishwasher
Clothes Washer
(circle selected)
Hoe Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
.��m. ,CFM: —_
Water Heater Tankless? Yes ❑ No ❑Hydronic
Heat in Floor ❑ Wall ❑
AC / Compressor /
Floor Drain/Floor Sink
Other:
Refrigerator watersupply(tor water/ice dispenser)
Other:
Boiler / Heat Pump /
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #,
,Elec#..�.-Olber;.
---- — BTUs: <100k-__w_,>100k,,,,,
Location(s),_w
Furnace
Air Handler / VAV
Gas #Elec
#_Other:
#ww-_www <10k----_ >lOk
Location (s)
(circle selected)
Location(s):
.��m. ,CFM: —_
�.,,,,,. .... .....,
BTUs:
AC / Compressor /
Other. __._..
BTUs:�.....
Location(s):- _ ..,,....�.
�
Boiler / Heat Pump /
Gas #
Elec #
Other:__—.,..........._......... #....................... BTUs:. ...... ...... .._,...<100k, ....................
..___.100k -500k, .
Roof Top Unit
HP:.............................<3,
......................
....... 3-15 _ ............................ Location(s)..__...... �--_-.,.w.w.w.-.._..
....��........._. ..
Dryer
(circle selected)
Outdoor BBQ
Hydronic Heating
Gas #_
_ Elec #.
.........In -Floor —Wall Radiant Boiler BTUs .,m__mm„
Location,---
TOTAL OUTLETS
Exhaust Fans (single
Bath #,......
Kitchen
#,Laundry # Other:_
mm....,,. #
duct)
Fireplace
Gas #_Elec
#_Other:
# Locallon(')e .-.-......
.............._. ........ _...........�
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:
Locations):... .w ..... .,.
Furnace
BTUs:
Water Heater
BTUs:_.......�..w_
Location(s):
w ........__...---�
Boiler
BTUs:
�-.-......�.. ...... Locations):..-._....._ ...... m_ ......._
Other. __._..
BTUs:�.....
Location(s):- _ ..,,....�.
�
w_...._..� ..�
Fireplace/Insert
.
......... ...
BTUs:—
__-r. ... Location(s) .........m..... _... -..__ r......m.....�
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORMC L:\Building New Folder 2010\DONE & x-f'erred to L -Building -New drive\Form C 2014.doex Updated: 1/17/2014