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DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5 h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 2 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
City ast , Zip). Parcel #:
PROJECT ADDRESS (Street, Suite #, Stat
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No i)�! /V//,-Y
APPLICANT. / / Phone: 1� � j' Fax: �JaS
rot G LC,
Address (Street, City, State .Zip):=,�' C� i °�' S SC" " 1-MailAddress:
PROP RTY OWNER: i Phone: Fax:
Address (Street, City, State, Zip):
LENDING AGENCY /� /
Address (Street, City, State', (Street, City, State, Zip):.
CONTRACTOR:*
Atd:rss (stet, City, Mate, Zip): d
*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
PLUMBING MECHANICAL 1 1, TANK.
DETAIL THE SCOPE OF WORK: ✓
E-Mail Address:
Phone: Fax:
E-Mail Address:
Phone: Fax:
E-Mail Address:
WA State License #/Exp. Date:
City Business License #/Exp. Date:
DEMOLITION
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 o
Edmonds.��
""
Print Nar
3e'* Owner Agent/Other (specify)
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
PLUMBING
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
w
Tub/S hoover
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
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—Other:
# BTUs: <100k >100k
Location(s)
Air Handler / VAV
Gas #
Elec #—Other:
#_CFM: <10k >10k
Location(s)
(circle selected)
—
AC / Compressor /
Boiler / Heat Pump /
Gas #—Elec
#—Other:-_
#_ BTUs: <100k,
100k-500k, 500k-lMil
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:
#_
duct)
Fireplace
Gas #—Elec
#—Other:
# Location($)
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):
Boiler
BTUs: Location(s):
Other:
BTUs: Location(s):
Fireplace/Insert
BTUs: Location(s):
Stove/Range/Oven
El;;;;;;
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\130NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
Bets O'Connor
From: Betsy O'Connor
Sent: Wednesday, November 16, 2016 8:57 AM
To: jackperawford@gmail.com; Nate Hegerberg; Kimberley Karrick; Tom Budinick;
tom@budinickassociates.com
Cc: 'Greg Close (gregory@paadvisors.com)'; Carol Eckart; Lyndsay Price;
'scottdelapconstruction@comcast.net'; eric@wolfcreekres.com; 'Randy Gordon'
Subject: FW: Salish Crossing - Water Line Repair
Importance: High
All
Just received word from Wolf Creek Services (8:50am) the pipe is repaired and the water is back on —Thanks again to
everyone for your cooperation.
Director of Operations
U
PACIFIC ASSES"
ADVISORS, INC.
From: Betsy O'Connor
Sent: Wednesday, November 16, 2016 6:45 AM
To: 'jackperawford@gmail.com'; 'Nate Hegerberg'; 'Kimberley Karrick'; 'tom@budinickassociates.com'; 'Tom Budinick'
Cc: 'Greg Close (gregory@paadvisors.com)'; Lyndsay Price; 'scottdelapconstruction@comcast.net';
'eric@wolfcreekres.com'
Subject: Salish Crossing - Water Line Repair
Importance: High
IMPORTANT NOTIFICATON
To: 190 Buildine Tenants
Brigid's Bottles
Cascadia Museum
Scratch Distillery
190 Sunset
Re: Water Line Repair
WATER WILL BE TURNED BACK ON THIS MORNING WEDNE'SDAY NOVEMBER
16T" AT 9:30AM
Final repairs are being performed this morning and the water will be turned back on at 9:30am. This was an extensive
repair and we do appreciate your patience and cooperation during this process.
If you have any questions or issues please contact me on my cell at 206-947-8549..
Again, Thanks very much for your understanding and cooperation.
Betsy O'Connor
Director of Operations
PACIFIC ASSES"
1,
A DVIS.0RSp INC.
600 108th Avenue NE, Suite 530, Bellevue, WA 98004
O 425.990.6200 xl 07 1 F 425.990.6207
www.paadvisors.com
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CITY OF EDMONDS
121 5T" AVENUE NORTH . EDMONDS, WA 96020
(425)771-0241 • FAX (425)771-0265
FINANCE AND INFORMATION SERVICES DEPARTMENT
The City of Edmonds offers a leak adjustment on customer bills for qualifying water leaks.
To qualify for an adjustment you must:
• NOT have received a previous adjustment in the past three years.
DAVE EARLING
MAYOR
• Have satisfactorily demonstrated a leak was undetected and caused by unusual circumstances
beyond control.
• Have taken action to repair the leak within 30 days of when the leak was discovered or within 30
days of being notified.
• Provide proof of repair within 90 days of the repair accompanied by a copy of the finalized water
service line permit. If the repair is exempt from permit, a signature is required from the City of
Edmonds Development Services Department indicating a permit is not required. For more
information, please call 425-771-0220.
If you determine you qualify and wish to apply for a Leak Adjustment, please complete this form and
return it to our office as soon as possible with the necessary receipts. NO ACTION CAN BE TAKEN
TO PROCESS YOUR ADJUSTMENT UNTIL INFORMATION ON THE COMPLETED
APPLICATION FORM IS RECEIVED.
APPLICATION FOR LEAK ADJUSTMENT CREDIT
Name: V'GT 1/.e> h �rD�
L L-G Date: w 5 w..
Service Address: �� ,�'�� �' A'� Glt°
......................................................................
__._._._
City:Mailing, � � � .State: ,�
Address i
J _� _ _ __.. _._ _ uu
City: (, �Ilewz,(e State: Zip Code:
Daytime Phone: 6"', Account Number: 6 —C�S0
Date you first noticed your leak: .d/ / t Date the leak was repaired: // /J5
....
Where was the leak located? (Please indicate below) --Ih 6lcllee�,( —5-/;;6
❑ Inside the house 11 Between the house and the water meter ❑ In the irrigation system
Are you a tenant at this property? E1 0 1 Lea - Landlords Name
Landlord's mailing address: � �� ,/45m8- r`: // ��,
City c c �e 1/ae w w StatdL)�Zip Code-Ys V1 Daytime Phone:
Please describe how your leak was identified or provide any additional facts you think might be helpful
below: (or attach an extra page):
By signing this request, I certify that I understand the terms and conditions of the City of Edmonds
Leak Adjustment Policy and acknowledge that I will not be eligible for an additional Leak
Adjustment in the next three year period
Customer S
Note:
FIA
f - ,,?5 --/ 7
• If you haven't received a bill through the date your leak was repaired, we will process your
claim after your next bill.
• If you have received a bill and your claim has not been processed, we suggest that you pay the
amount due by the due date to avoid delinquent charges. The adjustment will be applied to
your next bill.
• This form does not relieve responsibility of payment. If approved, the City will only adjust up
to three billing cycles.
CITY OF EDMONDS USE ONLY
Permit Exemption AVproved By:
Date: I.