20161020110114.pdf'a DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A 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 F_j NOV
Associated Permit #:
APPLICANT: � /
Phone: :[Fax:
e -k
Address (Street, City, State, Zip):
E -Mail Address:
ze 5 � 1
PROPERTY OWNER: 4 ��'
CC � r
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip).
E -Mail Address:
CONTRACTOR:*F
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Phone: ax:
S
2��. 25 -5 7d
Address (Street, City, State, Zip):
E -Mail Address:
WA State License iltlSsp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
:.u7� �c °
LI
in the City. Contact the City Clerk's Office at 425.775.2525
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City Business License : #/Exp. Date:
PLUMBING 6 MECHANICAL TANK
DEMOLITION
DETAIL 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 to the City of
Edmonds.
Print Name:✓•, Owner Agent/Other ® (specify): ________•••m,
..... ........ ....
Signature: y Date: [' (r
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FORM C LABuilding New Folder 2010\130NE & 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
_vv
Elec #Other:
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Location(s)
Water Service Line
/
Tub/Shower
#_.—Other:,__,_,
Drinking Fountain
Location(s)
Dishwasher
(circle selected)
Clothes Washer
BTUs: Location(s):,
Hose Bib
Stove/Range/Oven
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
AC / Compressor /
Water Heater Tankless? Yes ❑ No ❑
Hydronic Heat in: Floor ❑ Wall ❑
Outdoor BBQ
Floor Drain/Floor Sink
Boiler / Heat Pump /
Other:
Elec #®Other:,_...........
Refrigerator water supply (for water/ice dispenser)
100k -500k, 500k-1Mil
Other:
Roof Top Unit
... ................. . . . . . . - ------
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #- _
Elec #Other:
,IT— ........ # ......... BTUs: <100k_ >100k_
Location(s)
BTUs: Location(s):,
Air Handler / VAV
Gas #_IT__,Elec
#_.—Other:,__,_,
# CFM: <10k— >10k
Location(s)
BTUs: Location(s): _
(circle selected)
Fireplace/Insert
BTUs: Location(s):,
,- -- -„�„ �, �_
Stove/Range/Oven
AC / Compressor /
Dryer
Outdoor BBQ
Boiler / Heat Pump /
Gas #
Elec #®Other:,_...........
., # BTUs: <100k,
100k -500k, 500k-1Mil
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 #_Olher:
#
duct)
_
._---- .....
Fireplace
Gas #—Elec#,......Other:
_ #,�� -, Location(s)
_IT -----______._.,-.._._._____._.__..._._._
Dryer Duct
a--- I
I
j
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s):,
Furnace
BTUs: ,....... Location(s):
Water Heater
BTUs: Location(s):,
Boiler
BTUs: Location(s)._......... ...........mm...... _..w._................. _.._------ . _..
Other:
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