20161114115211.pdfDEVELOPMENT SERVICES
�f� w�➢l� "��J �PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
Est l 121 5t' 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 #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No V
APPLICANT: /1r� Ph ne: Tax:
l tf47 C— � -`/21-5
Address (Street, City, State, Zip): E-Mail Address:
?8l �� c� a 9� �. � �/ e Cor, C*s?
PROPERTY OW ER: /� Phone: T7777—
Address (Street, City State, Zip):
SIIEND G AGENCY•
� , � I E-Mail Address:
A' ens (Street, City, State, Zip): E-Mail Address:
CONTRACTOR:* �{�`�� s-1 '� S V �''1%/.mil � Phone:
( y „ !ip), E-Mail Address,
Address Street, City, Matte vCf/
Fax:
Fax:
WA State License It/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:
PLUMBING Lj MECHANICAL I I TANK I I DEMOLITION
DETAIL THE SCOPE OF WORK:.
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: �4;: 2 Owner
u _ ......_ 91 Agent/ Cher ❑ (specify): _.
Signature: _ __ Date:I,„1�
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New driveTorm C 2014.docx Updated: 1/17/2014
a
Fixture Type (new and relocated)
Water Closet (Toilet)
Sink (kitchen, lay, lavatory, bar, eye wash, etc.)
Tub/Shower
--_-......................... __
Dishwasher-�
Hose Bib
Water Heater Tankless? Yes ❑ No ❑
Floor Drain/Floor Sink
Refrigerator water supply (for water/ice dispenser)
Total # Fixture Type (new and relocated)
Pressure Reduction Valve/Pressure Regulator
'Water Service Line
Drinking Fountain
...
Clothes Washer
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Hydronic Heat in: Floor ❑ Wall ❑
Other:
Other:
Total #
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #_-Elec
#_ .._.tlther:
#^ BTUs: <100k, >100k,_,,......,
Location(s),__..._.,,,,,,,,
Air Handler / VAV
Gas #_Elec
#
Otlter.,# CFM: <10k >10k
Location(s)�
(circle selected)
.....................................
w______----w_.....m . ................................
AC / Compressor /
Boiler / Heat Pump /
Gas #
Elec$i...............
.011ter:,_...--......... # 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 # t,)ttter:-.
#�
duct)
Fireplace
Gas #Elec
#_Other:
#
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: ......... . ...... Location(s): ..............
Furnace
BTUs: , .ocation(s):............ ._............................. _.__............................... .................................
Water Heater
BTUs: Location(s):
Boiler
BTUs: -----� Location(s):
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