20161006161857.pdfAl
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
� PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
St 1 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 #:
9033
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT:
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Phone: 1"^ax:
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Address (Street, City, State, Zip):
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E-Mail Address:
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PR PERTY OWNIR:
Phone: Fax:
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Address (Street, City, State, Zip):
E-Mail Address:
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LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
Phone: Fax:
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93a 0717 IdO4,133 IT7
Address treetCity, State, Zip):
E-Mail Address:
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WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work 'Sb ., ,,
in the City. Contact the City Clerk's Office at 425.775.2525
City License Date:
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PLUMBING MECHANICAL TANK Ll DEMOLITION
DETAIL THE SCOPE OF WORK:._ m
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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: ( t t _ �_
Owner El Agent/Other 2(specify):
Signature:
Date:
FORM C LABuilding New Folder 2010\DONE & x-ferred to LrBuilding-New drive\Form C 2014.docx 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:
ILI
Refrigerator water su11 pp11 ly (tor water/ice dispenser)
11
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Other:
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: _ Location(s):
Furnace
BTUs: ., Location(s).__,__,,,,___
Water Heater
BTUs:
Boiler
BTUs:. Location(s):
Other:
BTUs:m..........................-------------------- Location(s):
Fireplace/Insert
BTUs:--.�.--...---------. Location(s):
_m.... ...-..---................................. .- ____
Stove/Range/Oven
_....................... ..._-....____-_._-----------------__--_ .....................................
Dryer
- . ---------------------------------------------------
Outdoor BBQ�_
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\DONE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014