20161205102450.pdfti ED It
�
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
I'st ➢
121 5`1, 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):
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes i - No
APPLICANT:
Address (Street, City State, Zip):
PROPERTY OWNER
Pa
Addra s ("Sl,lcct� City, State, Zip): „
LENDING AGENCY:
Address (Street, City, State, Zip):
CONTRACTOR:*
Address Street, City,State, Zip):
*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
PLUMBING I I MECHANICAL 10M$ TANK
Parcel #:
Associated Permit #:
6mzo 0,�5--�
lhone: Fax:
2_+ k 3^fig" S
E-Mail Address: II
cl r � ® hPra ��
�
Phone. II Faxc
I
Phope:., Fax:
E-Mail Atldo Ns. n
co
WA State l.icel se wti ale; '
f�:.ity ; usiness License #/Exp. Date:
DEMOLITION
e).w.I
DETAIL THE SCOPE OF W012K_ 1�t R-1`e:... m. L... --_ y�
I declare under penalty of perjury la11 w11 s 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 .... �J ...........a ._., Owner Z Agent/Other ❑ (specify):
�' � � _
r
Signature:�� ... _ ....... Date 5.__.... �..�._m —
FORM C L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
PLUMBING
Fixture Type (new and relocated)
Total #
FIXTURE COUNT
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
_..
Pressure Reduction Valve/Pressure Regulator
d y, lavatory, bar, wash, et (kitchen, laundry, c.)
Sink (kitchen,
Water Service Line
Tub/Shower
Drinking Fountain
.----------
Dishwasher........................�............eme _.
Clothes Washer
Hose Bib
Backflow Prevention Device (e.g. auPA, DCDA, Ava)
. _ _ wmwm.._.......� -.
Water Heater Tankless. Yes ❑ No
_ ...... ..._
_ _........ ..... _
Hydronic Heat in: Floor ❑ Wall [_]
_....... � �..
Floor Drain/Floor Sink
Other:
Refrigerator water supply (tor water/ice dispenser)
Other:
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #_Elec
#
Other: , W # BTUs: <100k >100k
Location(s) 0
Air Handler / VAV
Gas #
Elec #_Other:
# CFM: <10k >10k_
Location(s)_,
(circle selected)
uu.,.,.....,,.
AC / Compressor /
Boiler / Heat Pump /
Gas #.
#,._...._,
tlllat r°...._......................m., ,. #_...................... BTUs:_.......... ___<100k. ................
_._..,_...100k-500k, _...... ................_500k-1Mil
Roof Top Unit
HP:
<3.............................
3-15, ...................�15-30 Location(s) ................_..�.... ..n
—.......
(circle selected)
Hydronic Heating
Gas #_Elec
#
In -Floor _Wall Radiant_ Boiler BTUs:
Location,.............
Exhaust Fans (single
Bath #
Kitchen
# # Laundry �,11.0�tt':�.,._.,.,m_.__...
.._.. .. .....w.w ..�.�.__..�
i duct)
_
Fireplace
Gas #
Elec #—Olhe
....,.._......... ____ #
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:.., . _-_
Location(s).......
Furnace
BTUs:........_ .... ,m
Location(s):_,.-
Water Heater
-
....._ mm BTUs: u......�..
Location(s):
.......
Boiler
..�........
._...�.�
BTUs: ,......_. _
Location(s): _ .... . _�...............z
Other.. .... ..._.._._
BTUs:.... -- __--...._
Location(s):�.e...._�......-_ .........�...... ..... ....�.
�. _...
Fireplace/Insert
BTUs.
Location(s) ,,,,,,
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-f'erred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014