20161006083052.pdfu DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
I„St 121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street Si , Suite #, City State, Zip):
Parcel #:
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IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
Associated Permit #:
APPLICANT:
e: a 9- S I 1 `i Fax:
Address Street, City, State, Zip):
1�019 5 PI too. �`�'I St Zv6 �ff02&
E-Mail A
Gdress:
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PROPERTY OWNER: �'
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Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
yND :'* AGENCY:
Phone: Fax:
2fts (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* �A, I Les
eQ / / / v I
67
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 V1 MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK:,
------------- -W&C
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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: �u �t+e 0 Owner A
Q g ent/Other ❑ (specify) ....
Signature:4,t _ Dater
FORM C L:\Building New Folder 2010\130NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014