20170309105206.pdf-et17 a Of i ° o325
DEVELOPMENT SERVICES
� s
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5t" Avenue N, Edmonds, WA 98020
Fsr• I g9'� Phone 425.771.0220 2 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): C(80-7,&
Parcel #:
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Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPI,ICANTTO n rn,� � �i
PIS' 11
Fax:
Address (Street, City. State, Zip):�
A
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PROkERTY OWNER- 1� A A' / '
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Phone:
Fax:
Address (St ect, ty� State, Zip):
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E-Mail Address:
LENDING AGENCY: A 1,&� T
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* I
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
City Business License #/Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING MECHANICAL I TANKI
I DEMOLITION
` ' Af-C-� N�
DETAIL THE SCOPE OF WORK:
V%j (7-W
1
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.
Print Nant 1� Owner M Agent/Other ❑ (specify):
Signature: v ` Date:
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 COUNT
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
I
Tub/Shower
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
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-1M11
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(s)
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
Furnace
BTUs: Location(s):
BTUs: Location(s):
Water Heater
Boiler
BTUs: Location(s):
BTUs: Location(s):
Other:
Fireplace/Insert
BTUs: Location(s):
BTUs: Location(s):
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