20170125154252.pdfAl
a" DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
t� 121 5`Avenue N, Edmonds, WA 98020
Phone 425.771.0220 4 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
Pl* w1ECT ADORP:. S'i (Stj;ce(, St,01 11, City Statte Zip). Parcel #:
VJr ' 99r dw
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No N
APPLICANT: j 1 Phone: Fax:
Address (St,
rt City, swt s, Zip)„ E-Mail Address:
KU
PROPERTY OWNER: ('4�Q Phone:
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:
p i1� CD
WA State License #/E p.. Date:
*Contractor must have a valid City of'Edinonds 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 .. d_� _ .. `... .µ...... F
e
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. r ,
(7
Print Name: ._w ... . ar . - Owne e.. genit"4: Cher ❑ (specify), .....
Signature: ...` " �....a �. Date
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New driveTorm C 2014.docx Updated: 1/17/2014
PLUMBING
FIXTURE COUNT
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
...... .,. ,,,,,.
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 0
Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink
Other:
-Refrigerator water supply (for water/ice dispenser)
Other:
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #
Elec #IT
Other:m,,,,,,,
# ,, BTUs: <100k,, . >100k__
„.. Location(s)
Air Handler / VAV
Gas #—
Elec #,—
#,_ CFM: <10k >10k-_
Location(s)_-.--.—,,,,,.
(circle selected)
.Other: ,,,,mmmm ........ _
e _
AC / Compressor /
Boiler / Heat Pump /
Gas #-v_._..Elec
#_.......,Other
:.................................................'9'_................
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
Location —
Exhaust Fans (single
Bath #.
Kitchen # Laundry #
Other:,,,,,,,,,,,„n.._....._
_._�#.,...
duct)
__..........
.........
Fireplace
Gas #_Elec
#_Other:
# Location(s)_
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:._
__
BTUs: .
� ...... Location(s):., � __ .......
Water Heater.......
BTUs: _ _
�_ w........... Location (s�)M'.-w �...�.
............ _.....-......_._.--�._ __.
Boiler
.�.._....................
BTUs: _ .._.
Location(s):....... U....----- .m...... . ��,,....... �.
..
Other ���� m _.._
-BTU
r.�.� Location(s)..:..... - ,
.-_.._......
Fire lace/Insert
— p
BTUs
.... ... �...w�,,,�.
�.__.
Locations) �..
._ �$"1�....., — ............
� �.o
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New di ive\Form C 2014.docx Updated: 1/17/2014