20170228165731.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5'h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 9 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
yz
Parcel #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No 12(
Associated Permit #:
APPLICANT:
V I aa OV
Phone:
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Fax:
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Address�Street, Cit State, Zip):
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E-Mail Address. 4
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PROPERTY OWNER:
Phone:
Fax:
Address (Street, Cit�, State, Zip):
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E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* V( A P
Phone:
Fax:
Address (Street, City, State, Zip):
GF-7 GqfA
E-Mail Address:
*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
A State License #/Exp. Date -
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C, Business License #/Exp. Date.
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PLUMBING MECHANICAL P-1 TANKI
I DEMOLITION[
DETAIL THE SCOPE OF WORK. _P4A96C42. wev,- !) C, S r 1 eq-.
I declare under penalty ofperjury laws that the information I have provided on this formlapplication 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.
Print Nam CW � 0 OwnerEl Agent/Other VI(specify):
Signature: Date: -z/-z ez/ 7
FORMC LABuilding New Folder 2010\DONE & x-ferred to LBuilding-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 E No E]
Hydronic Heat in: FloorE] Wall E]
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
o I Dim I rag Ewa
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—Other:--
#_ BTUs: <100k_ >100k—
Location(s)
Air Handier / VAV
(circle selected)
Gas #—Elec
#—Other:—
#_CFM: <10k— >10k—
Location(s)
AC / Compressor
Boiler / Heat Pump
Roof Top Unit
(circle selected)
Gas #—Elec
HP:
#—Other:—
<3,3-15,15-30
#_ BTUs:—<100k,
Location(s)
100k-500k, —500k-lMil
Hydronic Heating
Gas #—Elec
#—In-Floor
—Wall Radiant Boiler BTUs:_
Location
Exhaust Fans (single
duco
Bath #
Kitchen # Laundry # —Other:
_#_
Fireplace
Gas #—Elec
#—Other:—
# Location(s)
Dryer Duct
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lwm��
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: '>�T 00l'o Location(s): L44A-,'�
Stove/Range/Oven
Dryer
Outdoor BBQ
I TOTAL OUTLETS -2_
FORMC LABuilding New Folder 2010\130NE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014