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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