20161103145204.pdf4� L®I1r
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DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`�' Avenue N, Edmonds, WA 98020
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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 #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No
APPLICANT: �jar��4. C ac\a��(y�� Phone: Fax:
( y, \� lr�w 9 J� E-Mail Address:
Address Street, Cit State, Zip)
PROPERTY OWNER: P\,�\ - Co\Aw QA 1 Phone: Fax:
Address (Street, City, State, Zip): �S t7G� \ l`��� S� 5l� E-Mail Address;
�Gc�v nvv�Ci' 'ZO
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip), E-Mail Address:
* ��a��t. •�. � axa�v~». a '� t Phone: Fax:
CONTRACTOR: �• � \a���
2S-7_7S7�
Address (Street, City, State, Zip);.v to ••.� v� E-Mail Address;
WA State License #/ xp. Date:
*Contractor must have a valid City (.r `1,_,d) aon ds• lacasaraess license prior to doing work SOt•�� � .�e � f �".µ.
in the City. Con..tac:t the Ci°y Clerk's Office at 425.77,5.2.525Cu.iiy Business License #/Exp. Date:
PLUMBING 1' MECHANICAL {' _ _ I TANK @._i DEMOLITION
DETAIL THE SCOPE OF W012K: _ t !lo,\. . ..............
p •... 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: m"tA Owner ❑ Agent/Other ; (specify): ._.w..............
a ..
Signature:
Date: W............_„ _ .... .
........ �..__ �.... .. �...� _ .... _...
FORM C L:\Building New Folder 2010\130NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014