20170110112548.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 9 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 #:
d I I G Q0 1 h Pi— SW EAMot1 S
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ NoM
Associated Permit #:
APPLICANT:
�et�SC_)C\
Phone: Fax:
�a `ice 514
Addres Street, City, State, Zip):
1 Q0�t PL , 1Y�on C� S
E-Mail Address:
e c9 ci i� ` MGM I C c3
PROPERTY OWNER:
Phone:
Fax:
SNMe
Address (Street, City, State, Zip);.
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip);
E-Mail Address:
ACTOR:*,...,.
CONTRACTOR:*
Phone: Fax:
� q-74
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:
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK:
+u }u
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: t C. ,y 4k re, a 61
Owner �ngent/Other ❑ (specify).„
,r�
Date:
Signature: WWW�
FORM C LABuilding New Folder 201000NE & x-ferred to L-Building-New drive\Form C 2014.doex Updated: 1/17/2014
Fixture Type (new and relocated) Total #
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
_.. ......... __.uu.__ . ......
Pressure Reduction Valve/Pressure Regulator
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Water Service Line
Tub/Shower
Drinking Fountain
Dishwasher
Clothes Washer
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes ❑ No ❑
Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
Equipment Type "I'l""I'll""I'll'll""I'll"I
. . ............
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas # L
Elec #,Other:
# BTUs: <100k >100k_
Location(s),_............... .............
Air Handler / VAV
Gas #
Elec #„
Other:
#CFM: <lOkw.......... >lOk,......
Location(s)------w--
(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)
Hydronic Heating
Gas #,
Elec #--In-Floor
...... Wall Radiant, ITITITITIT_ Boiler BTUs:
____ Location.
Exhaust Fans (single
duct)
Bath #
__..... Kitchen
# Laundry #
Other:
#
Fireplace
Gas #,.,
_Elec #,_Other:.
_ .
#,., Location(s)
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s):
Furnace
BTUs: _._ _ Location(s):_.................... ......... ............
Water Heater
BTUs: Location(s): IT. .......... „__
Boiler
BTUs: Location(s): _.__................................ W
Other:.. _ _
BTUs: Location(s):,
Fireplace/Insert
BTUs: Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 201MDONE & x-ferred to LrBuilding-New drive\Form C 2014.docx Updated: 1/17/2014