20170222105631.pdf;n
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
9
121 5'h Avenue N, Edmonds, WA 98020
t
Plione 425.771.0220 2 Fax 425.771.0221
City of Edmonds
PLEASEREFER 70 711E PLUMB NG & MECHANICAL CRECKLISTFOR SU. M17TAL REQUIREMEArn,
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
8103 190th St SW, Edmonds, WA 98026
00481600100802
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No7
i Associated Permit #:
APPLICANT:
h�ne:
�t°ti-547-8347 6-548-9352
Filco Company Inc.
Address (Street, Ct , State, Zt ):
1)0 Box 31228 eattle,, wa,stiiii ii:tirt 981.03
E-Mail Address:
info@filcoenviro.com
PROPERTY OWNER:
Gary He land
Phone: Fax:
206-972-0015
Address (Street, City, State, Zip):
E-Mail Address:
8103 190th St SW Edmonds, WA 98026
garV.hepland@outlook.com
LENDING AGENCY:
Phone: Fax.:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
Phone: Fax:
ilco CornjUany Inc.
206-547-8347 1-06-548-9352
Address (Street, City, State, Zip):
E-Mail Address:
PO Box 31228 Seattle, Washington 98103
info@filcoenviro.com
*Contractor must h4 e avaalidCity of Edmonds business license
+'A State Liceo e #/Exp. ,D :
prior to doing work 1�"ILCOC1080 iU 11/ 10/"201 5
rn the City. Contact the City Clerk's Office of 425.775.2525
ty s mess License #/ " t
PLUMBING MECHANICAL TANDEMOLITION
DETAIL THE, SCOPE OF WORK: i�ltlt�a rinse anci fill 'iti glace with 11min, one 300 allorl
residential heating oil tank. Cut vent and fill pipe below grade.
I
I declare underpenaCtlu ofperjury lows that the inforrnotlon I haveprovided on tltts ormlapplaic flan Is trite, correct and complete,
and than I am the properly owner or dra(p authorized went of the property oivner to submit as permit application to the C' V of
,Edttronds.
7 / 0-1 /�
Print Name: �
Owner ❑ Agertt/Other 2(specify): Contractor
Signature:
Date:
FORM C 1„A40din ''Newv Folder 2010tt NE dt x-ferred to L-Boiidin New drivclFDnn C 2014,doex Updated: 1/17/2014
Type of Gas/Air/Vacuum System (new and relocated) Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
..........
Medical — Surgical Vacuum
. ..... . .....
...............................
Other:
TOTAL OUTLETS
TA.NK#1
TANK #2
Method of Abandonment
Method of Abandonment
Fill in Fill Material foam
Fill in Place Fill Material
Removal
Removal
Number of Gallons: 300 gallon
Number of Gallons:
Critical Areas Determination: Study Required
Conditional Waiver ❑ Waiver
Type of structure to be demolished (e.g. house, shed, garage, etc.):
Floor area of structure to be demolished:
sq. ft.
Critical Areas Determination-. Study Required,E]
Conditional Waiver 0 WaiverEl
PSCAA Case No.
AHERA Survey done? (required)
Additional comments:
FORM C L-ABudding Newt older 201(ADONE & x-ferred to I. -Building -New ddvffonn C 2014.docx Updated: 1117/2014