20161216102832.pdfCity of Edmonds
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5"' Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A Fax 425.771.0221
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLISTFOR SUBMI77AL REQUIREMENTS
4, 0ty 4tlte, Zi Parcel #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No
APPLICANT: 6� n Se e— i ,...'Q—� 1rW� ?r n6 1^cdx;':
Address (S , C.i e i a : E-M .1 dres:
Sgwtte, �3� Lv1LV''IO S �� ���� .AJ , � �f r14cio_, r
PROPERTY OWNER: Fax:
J� w�c� °� Phone: 27-C q�Rg
AddRes; (Sire I1, City, slaw", � E-Ntail
d
LENDING AGENCY:. Phone: VFax:
A_\
Address (Street, City, State, Zip): E-Mail Address:
CONTRACTOR:* � lcy— 0 So 1 Phnzalk,r Fax:
✓L J �oh5 L 1. SO 1117
Address (Street, C i t't:, 1r): -M1ti1 t^ tqr1 ss:
1 �'3 *a( i t�
Contractor must have a Y f p b
valid City o Edmonds business license prior to doing work
in the City. Contact the City Clerk's Office at 425.775.2525 City Business License if/Exp. Date:
PLUMBING MECHANICAL I I TANK DEMOLITION
DETAIL THE � C70M O'F WORT . (,�
-k I A,,
I declare under penally of perjury laws that the information I have provided on this forma/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 Natne: ......#7 Owner ElAgent/Other M (specify) ( -off
...
Signature: ... ._ Date .1.1?....... �"�� ,,......
FORM C LABuildiug New Folder 2010\DONE & x-ferred to L-Buildirig-New drive\Form C 2014.docx Updated: 1/17/2014
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
2-1
Pressure Reduction Valve/Pressure Regulator
il
..........
_.... __-,
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
..... ._µ..
.
,__ ... _ ..... __ —
Water Service Line
.. __. ...... w_
Tub/Shower
�
Z
Drinking Fountain
� w,-........ �...__ M.. ..... ....�.�_. -
--
Dishwasher. ....... � .......
llishwasher. _m.. ...
�..m...._..
Clothes Washer..m_..
__ .. . ........ _
{
_ l ........,
_ ..... ....-_
Hose
e Bib
AVB)
Ba Device (e.g. RBPA DCDA, AVl3)
ckflow Prevention (e._ ..
..... .....e.
... _.
Water Heater Tankless
.._ _-- . _.... Yes ❑ No � ......
�.� ....-...
�......A,
......-. n ._ _.
Hy„dronic Heat in�Floor ❑ Wall...❑ ...........
m.......
Floor Drain/Floor Sink
Other:
.... ....-_ .w.... ..... -----------
......................_
Ref rigerator water supply (for water/ice dispenser)
Other:
!Eq�ui!pmenffype
MECHANICA
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #
Elec #
Other:
# BTUs: <100k_ >100k
Location(s),_,_.,___ ...,..
Air Handler / VAV
Gas #
Elec #
Other:
# CFM: <10k >10k
Location(s).,,,,,,,,,,,,,,,
(circle selected)
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)
H dronic Heating
Y g
Gas #m—DL;I
ec #
In -Floor Wall Radiant_ Boiler BTUs:
_Location ,..�,.
Exhaust Fans (single
Bath #
Kitchen # Laundry #
tlth►m ......... ._,. _.
�,
.M......... .# ....,
,... ...... ._ .
duct)
Fireplace
Gas #
Elec #_Other:
# Location(s),____
...,,, ... _ ......
Dryer Duct
FORM C L:\L3uildiiig New Folder 201 MONE & x-(erred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014