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20161212164253.pdft)1 E1,1h/0 l .�. � DEVELOPMENT SERVICES PLUMBING, MECHANICAL, TANK, & DEMOLITION PERMIT APPLICATION 121 51h Avenue N, Edmonds, WA 98020 St- 1 1 ° 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 #: a 5-" s�j *30 3 Associated Permit #: IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No APPLICANT: t Phone: Fax: Address (Street, City, State, Zip): � � C4Y�J 1:°-Main Address: PROPERTY OWNER: Phone: Address (Street, City, State, Zip): E=Mail Address: LENDING AGENCY: Phone: Fax: Address (Street, City, ,State, Zip); 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: PERMI"I'APPL[CATION POW PLUMBING MECHANICAL TANK DEMOLITION DETAIL'I'HE SCOPE OF WORK: ... /I/�Y PiY� 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.'w- Print Name �....._ .....-_--- Owner, Agent/Other XT (Ipecify) �N- o�ta Signature: _ ... _. ...: .. .. .::.. ....... .....m M....� Date." _. ...W. _ FORM C L:\Building New Folder 2010\DONE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014 PLUMBINGFIXTURE Fixture Type (new and relocated) Total # COUNT Fixture Type (new and relocated) Total # Water Closet (Toilet) r�� Pressure Reduction Valve/Pressure Regulator bar, eye wash, etc.) Sink (kitchen, laundry, lavatory,m Water Service Line Tub/Shower .............-_______._.....................� r DrinkingFountain ....... __ ................ Dishwasher Clothes Washer ------ ......... ........ ......... Hose Bib Backflow Prevention Device (e.g. RBPA, DCDA, AVB) __.._._.....-_ _,..� � Yes Water Heater TanklessEl ..�.... _-..v.. Hydronic Heat in Floor ❑ Wall � ..�-.....-...-.,.,...._....._-� ❑ ..............�.�,,,........w.�.� Floor Drain/Floor Sink Other: %Refrigerator water supply (for water/ice dispenser) Other: Equipment Type Appliance/Equipment Information (new and relocated) Total # Furnace Gas #Elec #_Other: ___ #_ BTUs: <100k ..__.., >100k Location(s) Air Handler / VAV Gas #_Elec #_Other: #—CFM: <lOk >lOk Location(s).._.w,,,,,,,,,,,,m,,,,naW,,,,,,,,,,_ (circle selected) a,,,,,,,,,,,,,W ___ AC / Compressor / Boiler / Heat Pump / Gas # Elec #_Other: # 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_ ,,--------------- I Exhaust Fans (single Bath #.. # ............. Other :.,_............ ..... .... ..... wm_ .._ _ ....,,,. _... A-,,,..m duct) .........Kitchen .......Laundry Fireplace Gas # Elec #_Other: # Location(s), ..,... ....... _.,.u.. _. Dryer Duct Appliance Type Appliance/Equipment Information (new and relocated) Total # AC Unit BTUs........., ..--w--. Location(s):.�w _....— Furnace BTUs .. _ .....Location(s) ,____................ Water Heater BTUs- -u .wee.._ Location(s) Boiler BTUs:. �.. ......... Location(s):.... ...m......... _ �.�-... m......- �� Other: .Ww�_n.......__�_ w.w-.e..... BTUs:........�m.. Location(s):. _�_ Fire �....._.���,.��..-�._... p Insert lace/ ... BTUs: m _ Locations):_.__._u..__ �e...._ _. m. r_._ .. Stove/Range/Oven Dryer Outdoor BBQ TOTAL OUTLETS FORM ( LABuddins New Folder 2010\DONE & x-ferred to L-Building-New drive\ForlTs C 2014.docx Updated: 1/17/2014