20160929084605.pdf41
n DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
't. 1 -011 Phone 425,771.0220 Q Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
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"TAI) '))ESS (Street, Suite #, City State, 'Zip): Parcel #:
7lo TA( X ve- yt./
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No Z
APPLICANT. Phone: Fax:
Z.►Ff�,Aacv'tzvrc�-� L..�-L YZ�s/��Y3$�i
( y E -Mail Address:
Address SUe,W, Cit State, Zip): /� PSC',C:dN
/V/o3 � c� A �-r tz 5 Svc ��i� L^/,4 9c� 3 90 ZI � ;.4cc: xA/aa
PROPERTY OWNER: Phone:Fax:
Address (Street, ily, Slate, Zi�� E -Mail Address:
/f sig �i✓
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip). E -Mail Address:
CONTRACTOR:* Phone: Fax:
Addte+;s
(Srett, Ci!.V, State,
+ zip
ly U.hilAddress:
" 3 ,9�
WA State License #/Exp, Date:
*Contractor must have a valid City of Edmonds business license prior to doing work 97/ C ;L-
in the City. Contact the City Clerk's Office at 425,775.2525 City Business License 01ll xp. Date:
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK: E:.,4% -Tal 4_jL� fTCji
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 permil application to the City of
Edmonds.
Print Name. L` � e%1; Owner ❑ Agent/OtherL�K(specify): ,w
Signature:Date
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FORM C LABuilding New Folder 2010\1DONE & x-ferred to L -Building -New driveTorm C 2014,docx Updated: 1/17/2014