20161003111125.pdfDEVELOPMENT SERVICES
���?'� '��,� PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
WI 121 5 h Avenue N, Edmonds, WA 98020
City of
f t �1 Edmonds Phone 425.771.0220 0. Fax 425.771.0221
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
0 ,5- zS (
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT: ' -1 Phone: Fax:
P1C_Vtf KVL 11 "� I HZE �7Z 12i q
Address (Street, City, State, Zip): E-M it d r s
s,[ -1,� b SS-S t •Cowl
PROPERTY OWNER: Phone: V Fax:
Address (Street, City, State, Zip); E-Mail Address:
LENDING AGENCY: Phone: Fax:
Address (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 Edmonds 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 6TANK DEMOLITION
DETAIL THE SCOPE OF WORK:
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: ` .__,,,,,,,,,,,,,__,,,,_____, Owner LfSLAgent/Other ❑ (specify):
.
Signature: Date I,�,.
FORM C LABuilding New Folder 201000NE & x-ferred to L Building -New drive\Form C 2014.doex Updated: 1/17/2014
AMM
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
--- .-.-.-................ ._.__............... ....
Tub/Shower Drinking Fountain
......
Dishwasher Clothes Washer
Hose Bib Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes ❑ No ❑ Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink Other:
Refrigerator water supply (for water/ice dispenser) 1 Other:
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #,_
, Elec #
,fit;;}ther.t_.....IT.ITITITIT - . #.— BTUs: <100k ,, >100k
_ Location(s)
Air Handler / VAV
Gas #,
Elec #
# CFM: <10k >10k_
Location(s).
(circle selected)
......
................Othei-.,____.._
/
AC / CompressorBoiler
/ Heat Pump /
GasHP
#^,,,,El<#(I3�15,
BTUs: <100k,
100k-500k, SOOk-Mil
Roof Top Unit
3,
�5-30 Locati
on(s)
(circle selected)
Hydronic Heating
Gas #_Elec
#
In -Floor _Wall Radiant— Boiler BTUs:
Location..- ............. � � _•• • ww_
Exhaust Fans (single
Bath #
Kitchen #_Laundry #
#
duct)_---�..---
_Other:
........................
Fireplace
Gas #_Elec
#..Other:
___ # Location(s)... ...... .-.......................................................
............... ...-.-........................
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s):_._._._._____ ..... .. uu _ ... w
Furnace
BTUs: ................... Location(s):
Water Heater
BTUs: Location(s):
Boiler
BTUs: Location(s):,_ITmmmmmmmmm .
Other:
BTUs: Location(s): _----.-.-.-------------w _........_._ _._
Fireplace/Insert
BTUs: •ITIT_•_•_•__•� Location(s): __. ..........
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014
Type of Gas/Air/Vacuum System (new and relocated) Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical — Surgical Vacuum
Other:
TOTAL OUTLETS
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
Fill in Place ❑ Fill Material,. _........ Fill in Place ❑ Fill Material,.,
Removal ❑ Removal ❑
Number of Gallons: _ _ Number of Gallons: ___..... ITITIT�
Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
a DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT CHECKLIST,
121 5 h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 Fax 425.771.0221
City of Edmonds
PROJECT ADDRESS:
Plans shall
be of sufficient clarity to indicate the location, nature, and extent
of the work
proposed,
and conform
to the provisions
of
the adopted
International Codes and City Ordinances.
SUBMITTAL REQUIREMENTS
?
o
The number indicates the number of copies for submittal( if
S.UP
�. K
W
applicable). Check marks indicate additional submittal
requirements that may apply to your project.
�e
Application Form C
1
1
1
1
Site Plan
3
1
Mechanical Plans
2
Manufacturer's Specifications/Cut Sheets
0
0
2
2
Elevation View for Roof Mounted EfloiDment
0 _
0
2
2
Structural Calculations
V/
�Piwr mbi Plans
2
Listed and Tested Fire St2EEjn Assemblies
2
Washington State Contractors License
Contractor's City of Edmonds Business License
V/
Critical Areas Determination or Checklist
1
�/
State Non -Residential Energy Code compliance forms
2
* Handouts
and Standard Details may be found on the City's website
www.mlin(Indswa.17,a°x
or can be
obtained at
City Hall
during
normal business hours.
Plans/calculation/reports
prepared by state licensed architects or professional
engineers
must
be stamped
and signed
by the
design
professional.
FORMIC LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014