20170105164619.pdfE It
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
" 121 5`h Avenue N, Edrzzonds, W 98020
'st, acy4t Phone 425.771.0220 V Fax 125.77 P.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUF3MI7TAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
(o -7 A"\�N
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ..
APPLICANT: vtt Phone:Fax:
i%S %37 —% Fax:
Address (Street, City, State, Zip): 1S (,,017 —7' j i., �,kjez W E-Mail Address:
PROPERTY OWNER: Y,\ Phone: Fax:
Address (Street, City, State, Zip): % (r` WQl W �1 E-Mai] Address:
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip); E-Mail Address:
CONTRACTOR:* Phone: Fax:
'ZS _7-75_73�_7
Address (Street, City, State, Zip): Ga � JG � tNA " E-Mail Address
f l AState �License itiN":xl . Date: —3Q V6
*Contractor must have a valid City of Edmonds business license prior to doing work V' e Z.
in the City. Contact the City Clerk's Office at425.775.2525 ('"rp BusirreS+, I,peelese:; #/Exp. Date:
�. 2„
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK t l ,„may " \ . ........\xi...........:.
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 ��^°�� ������,.�..,. ..........,__ Owner ❑Agent/Other .._,'(speci*ry): --
Signature;_ _...... ....� Date: _ 1 ._
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-building-New drive\Form C 2014.doex Updated: 1/17/2014
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #_........Flee
#
.....Other: ............................#.........,.,.-,- BTUs: <100k...........>100k
Location(s)_..........._...,..............................
Air Handler / VAV
Gas #,,
#
Other # CFM: <lOk >lOk
Location(s)
(circle selected)
,__Elec
-_ -- --- .._.
AC / Compressor /
Boiler / Heat Pump /
Gas #-------
„Elec #,.....
-- .... Other, _ ........... it BTUs: . ...._<100k, . ,.
100k-500k, 500k-IMil
Roof Top Unit
HP:
<3,
3-15, 15-30 Location(s)
(circle selected)
Hydronic Heating
Gas #---_.-Elec
#
In -Floor ,,,,,, Wall Radiant.,,,.,- Boiler BTUs w,
Location ----- ,_m __ .
Exhaust Fans (single
Bath #
Kitchen
# Laundry # Other:_
#
duct)
...._. ..... ..
..............
Fireplace
Gas #
Elec #
Other: # Laaca tii an(b._ _....._... _. -w.w
.... �......W......
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:
_.._.._ Location (s):.... _--- .. _..._
......._ u... n�..
Furnace
BTUs; ...
Location(s):-- . ........................ .—.
- -- - -
- - - - -----------------
_....
Water Heater
-.-...n
BTUs.
Location(s): .........--------� - ..........
Boiler
BTUs.
-
Other m-.
BTUs:..
..--- __ _ �. Location(s):..... ........... .................... _ .
Fireplace/Insert
Fireplace/I
, m.
BTUs:........
. .--Locations):,....... _... �� ��
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C L,:\Building; New Folder 2010\GONE: & x-ferred to L-Building;-New drive\Form C 2014.docx Updated: 1/17/2014