20161130142002.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 It Fax 425.771.0221
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip)„ Parcel #:
5 _w. ✓
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No,�
APPLICANT: Phone: _T Fax:
�t� S
Address (Street, City, State, Zip): E-Mail Address:
PROPEII°'Y OW'NFR: Phone: Fax:
Address (St,tct, City Slatd, 7`lp).- E-Mail Address:
LENDING AGENCY. Phone: Fax:
Address (Street, City, State, Lip): E-Mail Address;
CONTRACTOR:* Phone: Fax'
Address (Street, City, State, Zip):. E-Mail Address:
WA State License #/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 MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK:. _ _.L°:......"1'!= .... ........
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: r��._�r.:.,? _ ......�.�....._. Owner 0 Agent/Other ❑ (specify):.®............. .................. ...
cr� Date:
FORM C LABuilding New Folder 2010\DONE & x-(erred to L Building -New driveTonn C 2014.docx Updated: 1/17/2014
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #
Elec #_Other:
# BTUs: <100k ,.,,., >100k_
Locahon(s).,_..... ,.. ,.
Air Handler / VAV
Gas #,
lf_
4'7tliter:�:# CFM: <10k >10k
Location (s)_„_ --r__ ��
(circle selected)
m,,,Elec
AC / Compressor /
Boiler / Heat Pump /
Gas #—Elec
#Other
: .......... ....v.... ........ _. #...................... 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 # Wmat"lffie ............, ...
_............ - r
duct)
Fireplace
Gas #
Elec #_Other:...
# L(Wation(s) .....___ --_-
.. .......... .,. _
Dryer Duct
FUEL GAS
Appliance Type Appliance/Equipment Information (new and relocated) Total #
AC Unit
BTUs:......m .. _ _....,
, Location(s) .... __.. �_ ..�. .._...
...�. _,.
Furnace
BTUs .......
Location(s):,.w ., m _— sae .. .e.......... ............
�.Water Heater
BTUs: ..,w _
. ..._ �m...._ . - .. ....._.
Boiler
m..._
_..._ �_...�..
BTUs: _
.., Location(s):
Other: .........-_._...
BTUs: ..
Location( )�M...._... _._ ................ ._.--.._........
Fire lace/Insert
BTUs; ...� m..
Location(s):, _....
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C 1-Muildiug; New Folder 2010\DONE & x-(erred to t.-Building-New drive\F`orin C 2014.docx Updated: 1/17/2014