20161031091851.pdf1 DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`Avenue N, Edmonds, WA 98020
I , t.lttl Phone 425.771.0220 # Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (,c AStreet, Suite #, City State, Zip): Parcel
1 #:
k\ CA �.. � ,o •� LP -A-
u Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT: 11 ,,
Address (Steel, City, State, Zip):
.7y 07
PROPERTY NER:
2 , . , 2�a'
Address (Street, City, State, ip):
111 v..�
LENDING AGENCY:
Address (Street, City, State, Zip):
CONTRACTORS
Addr (Street, City, State, Zip):
( Phone: Fax:
E-Mail Address:
Q u) -tiaz 1.
Phone: Fax:
S113Z'._
E-Mail Address:
Phone: Fax:
E-Mail Address:
Pho= Fax:
E-Mail Address:
EWA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing workin the City. Contact the City Clerk's Office at 425.775.2525 ty Business L'i ense 11/Ex Date:
`Y " C1
PERMI'll"APPLICATION FOR:
PLUMBING MECHANICAL TANK - DEMO—L—IT-1-0-IT.-17
DETAIL THE SCOPE OF WOI 'K _:... _A 0.�:.....XL4 `� ee �" , ..... ...n _ ...
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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: �,�.,, v..o.,.,, Owner Agent/Other ❑ (specify):
Signature: b ' 3/ — / L
,- Date: -
FORM C'. L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.doex Updated: 1/17/2014