20170109102054.pdfa 4
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
`
PERMIT APPLICATION
121 5"' Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & ME, CHANICA/ CFIECKL,IST'F'OR SUBMITTAL, REQUIIZF_MENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
8--53 Z
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No ✓Z
APPLICANT: ! L�� ph
3& .32o 76s Fax:
(aIS,
Address (Street City, State, Zip): E-Mail tt1c$�'e.": �1�"���
7�3 �/ ado 5 �- �o �v,//r �J�9�'z�` _-
PROP RT OWNER: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
56,014
LENDING AGENCY. Phone: Fax:
Address (Street, City, State, Zip):. E-Mail Address:
CONTRACTOR:* Phone: Fax:
Saw- Cam) �" . ,� ca . �
Address (Street, City, State, Zip): E-Mail Address:
WA St I IC 0se, 11F1 '~vpI Rate:
Contractor must have a valid City of' Edmonds business license prior to doing work °^ 1Ctr '�"
�,s I ease #/Exp. Date:
intheCity. Contact the City Clerk's Office at 425. 775.2525 City Btl su
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK:., y
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
Ednxonds.
Print Nairte:�� cl°I&/GICI. r (specify)-' - `.. Owner p y):
` ., ®.... Date: _ _✓ /..... ��/ �.°
A0_
FORM C LABuilding New Folder 2010\DONE & x-ferred to L, t3uilding-New driveTbrin C 20t4,docx Updated: 1/17/2014
PLUMBING
FIXTURE COUNT
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
------------------- -- ..u_. ... ......... ....
Pressure Reduction Valve/Pressure Regulator
®®------
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Water Service Line
Tub/Shower
.... _
n
Drinking Fountain � � ..... ... ... � ...,
gF..
,, -
.......... _
Dishwasher
Clothes Washer
Hose Bib
Backflow Prevention Device (e.. RBPA, DCDA, Avu)
�wwww.._...._...-.... Yes ❑ No ❑
�
Water Heater Tankless .
._ ....u.��
Hydronic Heat in. Floo... ...��...... �.�.� ... __•m��. ..
r❑ Wall❑
....
Floor Drain/Floor Sink
Other:
Refrigerator water ...._........ ( Supply (for water/ice dispenser)
Other:
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #
rnElec iR
Other: # ....I BTUs: <100k >100k—
_ �. w � _,.�.-_�-......
Location(s), ........
.............�..--......... .............�..--
Air Handler / VAV
Gas #
. _.
Elec #_Other:
#, CFM: <10k_ >10k
Location(s),.._ _ --�
(circle selected)
-, ,,,
AC / Compressor /
Boiler / Heat Pump /
Gas #
Elec 4
_Other: 1R BTUs: <100k,
100k-500k, 500k-1Mil
Roof Top Unit
HP:
<3,
3-15, 15-30 Location(s) ,-.-_
(circle selected)
...._..�.........__ .
mc Heating
Hydro '
Gas #Elec
#
ant_ Boiler BTUs:
In -Floor _Wall Radiant—
LocationF ....
Exhaust Fans (single
Bath #_Kitchen
#_Laundry # Other ,,,.............
.. __---_ # -.
duct)
..-- _ .....
-...._.._
.
Fireplace
Gas #Elec
#
Other: # Location(s) ........... ........._
...m.
............. .... .,.. ..... ........
Dryer Duct
FORMC L:\Building New folder 2010\DONE & x-fened to 1 Building -New drive\form C, 2014.docx Updated: 1/0/2014