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DEVELOPMENT SERVICES
��1��� '�'' j 1 PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h 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 #:
117 5-1` 1 ,
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Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT: /�
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Phone:
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Fax:
Address (Street, City, State, Zip): jaKlq 6e- 3s-t', S}- 4f7 eue� lc
E-Mail ddress; I 1
6164410
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PROPERTY OWNER:
t
Phone: Fax:
906- 61.1- 0-7 -76
Address (Street, City, State, Zip):
E-Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip);
E-Mail Address:
CONTRACTOR:* /, L p� _
CjGtGTC'I'ovs �1/�i �N�
Phone: Fax:
5_7�-
Address (Street, City, State, Zip):
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E- it A ress:
�Gr�n�sE 0cWfYto—KIl'ST.Co
*Contractor must have a valid City of Edmonds business license prior to doing work
WA St to License 111 xp. Date;
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in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
PLUMBING MECHANICAL TANK
DEMOLITION
rT R P�A
DETAIL THE SCOPE OF WORK: �..
&4- vk h r e ..V.LY ...........m ...................... .....
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; Owner ❑ Agent/Other
Y (specify): e-ei'A
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Signature: ✓r'' Date: n f / 0 0
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FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.doex Updated: 1/17/2014
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)
Other:
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #__-Elec
#_--Other:
# BTUs <100k_ . >100kM
......... Location(s)
Air Handler / VAV
(circle selected)
Gas #,v,,,
Elec #Other:
#_ CFM: <10k__ >10k _
Location(s)
AC / Compressor /
Boiler / Heat Pump /
Gas # w-._,Elec
# ,-
- Other: # BTUs: ....................................<100k, ............_.®100k-500k,
500k-lMil
Roof Top Unit
HP:
<3, ________3-15,
,_____15-30 Location(s)
(circle selected)
Hydronic Heating
Gas #_Elec
#In
-Floor _Wall Radiant-.-,,,,. Boiler BTUs:
Location
Exhaust Fans (single
Bath #_Kitchen
#_Laundry # Other:-
#�
duct)
Fireplace
Gas #—
Elec #
01her _ ..........................................--- # Location(s)
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s): _ _.
Furnace
BTUs: - _ Location(s):,_,,._
Water Heater
BTUs: ......, - . __- Location(s):
Boiler
«wawa_
I BTUs: Location(s):
Other: m .... _....._
.............
BTUs ... Location(s):_
Fireplace/Insert
BTUs: 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