20170112112025.pdfDEVELOPMENT SERVICES
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PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`s Avenue N, Edmonds, WA 98020
Phone 425.771.0220 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 #:
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Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No K"
APPLICANT:
Phone: Fax:
Address (Street City Stale, Zip):
E-Mail Address:
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PROPERTY OWNER:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
LENDING AiiPE Cie°:
Phone:
Fax:
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Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
Phone: Fax:
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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:
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PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK: .__ �..�. �.•••••• •..-•__�
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 properly owner to submit a permit application to the City of
Edmonds.
Print Name: .� mm Owner El Agent/Other ❑ (specify):
Signature: _ ..: Date:i
FORM C LABuilding New Folder 2010\130NE & x-ferred to LrBuilding-New drive\Form C 2014.docx Updated: 1/17/2014