20161010132115.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
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, Suite #,, City State, Zip):
Parcel #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
Associated Permit #:
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Address (Street, City, tate, Zip):
E- ai Address:
PROPER1'"'�" O "R:
Phone:
?-�?o�
Fax:
Address (Street, ' ty, State, Zip):
E-Mail Address:
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LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address..
CONTRAC"I' _ r -w" " c
Znral
Phf e: 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:
AV &tJ
PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL 7V7,
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 tot ity of
Edmonds.
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PrintName: ........... Owner Ada:ltitt�ler (specify), ..
Signature. ....._. ........ Date: �.� .�..�
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New driveTorm 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:
Refrigerator water supply (for water/ice dispenser) Other:
Equipment Type
Furnace
Gas #__
Elec #f
MECHANICAL
Appliance/Equipment Information (new and relocated)
011 er. # .... BTUs: BTUs: <100k , >100k__ _ Location(s)_„
Total #
Air Handler / VAV
(circle selected)
Gas #^Elec
#
�C:Atltet :nIT� . # CFM: <10k >10k
Location(s)
AC / Compressor /
Boiler / Heat Pump /
Gas #,
Elec #—Other:,
# BTUs: <100k,
100k-500k, 500k-lMil
Roof Top Unit
HP: .............................
<3,
3-15, 15-30 Location(s) _,___
(circle
(circle selected)
.............
Hydronic Heating
Gas #
Elec #_In
-Floor _Wall Radiant.._,. Boiler BTUs:.,
Location —
Exhaust Fans (single
Bath #_Kitchen
# Laundry # Other:
#
duct)
Fireplace
Gas #,Elec
# ................
Otha r. _ #, I --------
=DryerDuct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s):,...........
Furnace
BTUs: ..,,,. Location(s):------- __.
Water Heater
BTUs:
Boiler
BTUs:.
Other: ................
BTUs: -... .......................................... --Location(s): w. _ ...... .........--------�
Fireplace/Insert
BTUs:-----�,.. Location(s): ...............
_...- ...._..
Stove/Range/Oven
_ .... .....--------------------.-.
www. ..
Dryer
Outdoor BBQ
.__........ . ._---
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-ferred to LrBuilding-New drive\Form C 2014.docx Updated: 1 /17/2014