20161115114614.pdftb DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
I`t 1�1 121 5"' 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 #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT: hr '1 I/ I Yl ..e
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Address (Street, City, SC �:, .�';(��'M: ,�.��
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PROPERTY OWNER:
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Phone: Fax:
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Address (Street, City, State, Zip):
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LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
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Phone: Fax:
ICJd —55,60
Address (Street, City, State, Zip),: m
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Contractor must have a valid City o Edmonds business license prior to doing work
e #/Exp. Date:
WA Stag. Livens �
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in the City. Contact the City Clerk's Office at 425.775.2525
FOR:
City Business I.i ense #/Ex . Date:
31-1,4
PERMIT APPLICATION
PLUMBING MECHANICAL TANK
DEMOLITION
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DETAIL THE SCOPE OF WORK �t...1 "s
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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.
�`�'...e_. Owner ❑ Agent/Other
(specify):...,.,..
Print Name: ..� .�.. ... ......
Signature: ^ .. ��` �� � a� :: ..� �_ �" .;1. Date:
FORM C L:\Building New Folder 2010\DONE & x-felled to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
TANK
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
�/ CeaVe C dN ">t°C°..? , Fill in Place Fill Material
Fill in Place Fill ..,.,.
Removal...._.................�............... Removal.._
Number o _ _�_.���...............���_.
f Gallons:..L' Number of Gallons:
Critical Areas Determination: Study Re u'�ed Condition q i • � al Waiver � Waiver
El
FORM C, LABuilding New Folder 2010WONE & x-(erred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014
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(Revised 6/16) Index-6.2