20160929101146.pdf❑ PARTIAL APPROVAL
Owner
Job Address
Type of Inspection
TO PERMITTEE AND/OR OWNER
❑ CORRECTION REQUIRED JO ENFORCEMENT VIOLATION
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Permit Number UD -m) — 12::SD
Site Contact I KIU L I O_g
❑ WORK DESCRIBED BELOW HAS BEEN INSPECTED AND APPROVED.
❑ APPROVED PLANS AND JOB CARD MUST BE AVAILABLE TO INSPECTOR ON SITE.
❑ CORRECTIONS LISTED BELOW MUST BE MADE BEFORE WORK CAN BE APPROVED
AND/OR THE NEXT PHASE OF WORK IS STARTED.
❑ RECALL FOR INSPECTION.
❑ REINSPECTION FEE MUST BE PAID PRIOR TO NEXT INSPECTION REQUEST.
STOP WORK -UNTIL AUTHORIZED TO C WTINUI: BY CITY INSPECTOR.
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THE ACTIONS OR CORRECTIONS INDICATED ABOVE ARE REQUIRED TO BE CORRECTED BY
(DATE) mm OR PENALTIES MAY BE APPLIED. FOR INSPECTION CALL 425-771-0220
Building ❑ Planning ❑ Engineering ❑ Fire ❑ Public Works
Inspector ......... Date 4 .
... ...:.:.... __.............. �_..... _- .........
TMS NOTICE TO REMAIN ON SITE
White: Permit File Buff: Applicant
„� � ,•,ter a,�d
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
m PERMIT APPLICATION
r�. 121 5`h Avenue N, Edmonds, WA 98020
't° 8 tt
City of Phone 425.771.0220 It Fax 425.771.0221
Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS ($treet, Suite #, City St to, I” p): Parcel #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No Y
APPLICANT: 9�kE!4� LE I Phone: Fax:
ub.12115
Address "StrccC„ Cityta e
S, /°) E -M it ddress:
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PROPERTY OWNER IP one: Fax:
a _� - v
Addr•es (St•eet�City State, ip E -M it Address:
"
(a .............. 1A�, kA o I.A.
M �6
LI;N1I i AGENCY: Phone: Fax:
2!S11 (Street, City, State, Zip)¢ E -Mail Address,,
CONTRACTOR:* Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of`Edrnonds business license prior to doing work
in the City. Contact the City C'lerk's Office at 425.775.2525 City Business License #/Exp. Date:
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK W� �... ... _.
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.
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Print Name: •�¢..i... Owner Agent/Other ❑ (specify)a' .,.....
Signature: -- �� , �a ., ...�m......_ Date: _...i' _�.'...............m_.__..
FORM C LABuilding New Folder 2010\DONE & x-ferred to L, -Building -New drive\Form C 2014.docx Updated: 1/17/2014
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
.............. _..................... ......... _. ....... .......
Fill in Place ❑ Fill Material_ ,,,,,_,m._w____� Fill in Place ❑ Fill Material-,-.,,,,,,
Removal � ......_�...�..� ........................_...... ._._.�.....���..._�.�..�.�__.���_........_.__....�......�.�.
Removal ❑
_....._
Number of Gallons _ __�..w.. _.._. _ Number of Gallons: m _ ... _... ��..............ee�
Critical Areas Stud Re Conditional Waiver ._._..�........
Cr' y RequiredE] ❑ ❑ Waiver ❑
FORM C L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Forrn C 2014.docx Updated: 1/17(2014