20170214153825.pdf1tr
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
l'st l %P Phone 425.771.0220 A Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): , a /
/0/0D� )) AVL ""
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
Address (Street, City, State, Zip):
PROPERTY OWNER: 5
1
Address (Street, City, State, Zip):
LENDING AGENCY:0N6—�
Address (Street, City, State, Zip):
CTOR:'*
vu.00
M
(Street, City, State, ZipL. '
o, (9) D f
Parcel #:
Associated Permit #:
�`?, �—f6 ' 3 2-
E-Mail Address:
LPhone:
PFa
E-Mail Address:
Phone:
Fax:
E-Mail Address;
�n
E-Mail Address:
Fax:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work t
in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
PLUMBING I I MECHANICAL L1 TANK Lj_ 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 property owner to submit a permit application to the City of
Edmonds.
9
Print Name "t�*' �' � � � ........ Owner A Agent/Other ❑ (specify):
Signature: �� ... _.. . .. ���,._"".. _ � Date:
FORM C LABuilding New Folder 2010\130NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
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.)
( y,
ff
.-......._-... ........�.
Water Service Line
Tub/Shower
Drinking Fountain
Dishwasher
Clothes Washer
Hose Bib....._
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
_.
� � No ❑
Water Heater Tankless. Yes
_
_
Hydronic Heat in: Floor ❑ 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 #_Elec
#_.Other:
— —
#.,— BTUs: <100k— >100k_ Location(s).mmm,m,m ...... ,.
Air Handler / VAV
Gas #_Elec
#_Other:_µµµµµµ,-
# CFM: <lOk_ >lOk_
(circle selected)
_..,_
AC / Compressor /
Boiler / Heat Pump /
Gas #.................
Elec #_
Other: , .w.-a a ,.,.. ........,
# BTUs: <100k,................. .............. 100k-500k, 500k-lMil
Roof Top Unit
HP:
<3, .
.. _ 3-15, ....................�15-30
Location(s) .wA _ ....�._......... ... - ....
(circle selected)
Hydronic Heating
Gas #_Elec
#_In
-Floor _Wall Radiant...— Boiler BTUs ......... tartuataoot IT_
Exhaust Fans (single
Bath #_Kitchen
#_Laundry #
duct)
Fireplace
p
Gas # ✓Elec #_Other:
... ___#_(
r
Dryer Duct
Appliance/Equipment Information (new and relocated)
Total #
Appliance Type
AC Unit
BTUs:
Furnace
BTUs: ,
_ Location(s): ......
Water Heater
BTUs:
. .
Boiler
BTUs: ,....�..,.,.,H._
Location(s):,
.._ m
Other: �....
BTUs:.
Location(s):_...............
Fireplace/Insert
BTUs
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014