20160929090455.pdfa`y*,,
City of Edmonds
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft Fax 425.771.0221
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PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
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IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
Associated Permit #:
APPLICANT:�>��\ ��� �
zoe . ��g 631 Y ax:
Address (Street, City, State, Zip):
2,:;- f+k S t
E -Mail Address: ,
-L�Wxaske_l &, om a_cksf
PROPERTY 1 Y t)'lV ER:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CON„„ tAC'17OII:
T t C ?\.KoAl U"
Phone: Fax:
20 6 4 -K3 -W) ,
Address (Street, (Ity, State, "Zip):
w�v1ou,nit i�rt
E -Mail Address:
�,r,w.c� ��cher eo
*Contractor must have a valid City of Edmonds business license prior to doing work
WA State License #/Exp.. Datte
in the City. Contact the City Clerk's Office at 425.775.2525
Ci¢v Business License #/Exp. Date:
PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK------
-- — -----.. .?LL ..
f� 6-- _ 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.
Print Name: e,✓�,.,._, ,. Owner Agent/Other ❑ (specify). „ ,
Signature: ._� - d �,........�.... .... Date
.. �.. .
FORM C L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.doex 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 (kitchen laundry, lavatory, bar, eye wash etc) Water Service Line �� 1 I
.... �... ..._ ........ _- ., -. ....— �� ..... _..m
Tub/Shower Drinking Fountain
� Dishwasher..........wm_— __..., ....._..---- ....,.
Clothes Washer
_.._ ... .—. ..... ..
Hose Bib Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Tankle Heater _ ....... � ❑ __._ ,. ...-.. Y ....... ❑ ...._� . ......__m.. ---__
ter ss? Yes No H dronic Heat in: Floor Wall ❑
Floor Drain/Floor Sink Other:
Refrigerator water supply (for water/ice dispenser) L'i
Other:
MECHANICAL
Equipment Type Appliance/Equipment Information (new and relocated) Total #
Furnace ( Gas #Elec #_Other: # BTUs: <100k_ >100k_ Location(s)
Air Handler / VAV
Gas #Elec #_ Other: #_CFM: <lOk_ >101c. Location(s)-
(circle selected)
,_____ .____ _____ ____ _ ------
AC / Compressor /
Boiler / Heat Pump /
Gas #.Elec #_Other:._____ .......... __'ikBTUs:.______..__<100k. ......... __100k -500k_ ------------ _500k-1Mil
Roof Top Unit
HP .........<3, .............. .3-15, ------------------ 15-30 Location(s),,, .----- ----_.
(circle selected)
Heating
Gas #Elec #_In -Floor Wall Radians Boiler BTUs:,_„ .................... _..... Location
[Hydronic
Exhaust Fans (single
Bath # # ,,._...._Laundry #.—Other: —# .._...
duct)
...........Kitchen
Fireplace I Gas # Elec #_Other: #_ Location(s)
Dryer Duct
FORM C', L:\Building New Folder 2014\DONE & x -fenced to L-Buildiog-New drive\Form C 2014 docx Updated: 1/17/2614