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DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 !R Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMI77AL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
4 CM 1 _7,'�,Ko St s W 9 bo_.1,�
Associated Permit #;
No�
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes
APPLICANT: Phone: Fax:
� reLnk-e Hzs z4 (4& w
Addrl ess Street, City, State, Zip): E-Mail Address:
5 �l � � Ei �AQ.. � C
�+
6 00 tirJ S 1 �J , e
PROPERTY OWN 1 Phone: Fax:
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:
*(."Orar„ractor rn..usl. have a valid City rlf Edrn..orads business license priorto doing work
in, the Cityr. C"oratreet the City Clerk's 'ire at 42.5�.77-5.25�2.5� City Business License #/Exp. Date:
PLUMBING MECHANICAL Ij TANK DEMOLITION
DETAIL THE SCOPE OF WORK:
1 declare under penalty of perjury laws that the information 1 have provided on this form/application is true, correct and complete,
and that 1 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 (specify): P '�
_ .. �...... ..... .
Signature: ........ �., _ ..-„ Date ,,..,. ` ....,.,` ....... .
FORM C L:\Building New Folder 2010\DONE & x-(erred to L-Building-New drive\Foriro C 2014.docx Updated: 1/17/2014
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #,
Elec#..._...._Otlla
.... „#_BTUs:<100k
>100k
Locations ...... __
Air Handler / VAV
Gas #_Elec
#_Other:
#CFM: <lOk_ >lOk
Location(s)µ„,WW,_,m,--...__,,.
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Gas #
Elec #
Other:
P BTUs:_ <100k,
100k-SOOk, 500k-1Mil
Roof op Unit
HP:
<3,
3-15, 15-30
Location(s) ......
........
(circle selected)
Hydronic Heating
Gas #Elec
#In
-Floor _Wall Radiant_ Boiler BTUs
Location �...._
Exhaust Fans (single
Bath #
#........Laundry # .
...Otl�twa .....
.. a
duct)
..-......__...................... ---
......._.........Kitchen
_..
-
Fireplace
Gas #
Elec #_Other:_
#_ Locat on(.S)„ _....... ... ,,,..........
...... ......_ . -._.__ __ ®........
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:..,,,. „
_- ._._.--- Location(s):.....- ..... ...... ............ ......
Furnace
BTUs:
._..,,,._.n. Location(s):IT.., ,------_ ...... _.
�..-.
Water..... ..
Heater
...........
BTUs: ...........
Location(s):
Boiler
BTUs:.............
. ............
Other...........
BTUs: ,
Location(s):.... .. .......... ................. .....�..
Fireplace/Insert
BTUs: ,,_
Location(s):.................... ...... _.. ........
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FC)FZ_M C l-,:\Building. New Folder 2010\DONE? & x-ferred to L.-Buildirsg-New drive\Form C 2014.docx Updated: 1/17/2014