20170327101531.pdf(P DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5h Avenue N, Edmonds, WA 98020
Phone 425.771.0220!k Fax 425.771.0221
City, of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
315 PFrP AVt4tAt-5 &)9M0t'r* IWI' q&Q-).0
Parcel #:
o0Y3c�A1,XD103 40/
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes 0 NoE]
Associated Permit #:
APPLICANT-
J( _ (Ar?
8 S,
P41one-
Fax:
Address (Street, City, State, Zip):
,;40(3 /,?& jtmLT J6,0 sl-i7t-
E)N4ail Address:
PROPERTY OWNER:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
Phone:
Fax:
Addr�ss (Street, City, State, Zi
,P406 jf6 3r"er Si-3 /A�-
E-Mail Address:
J,�Ee� Z>aS6Lqri opos N w
*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
WA State License #/Exp. Date -
Dl3.36L:5L--j3qdy_ i /3 6/076
1C I mess Lgiens # p Date:
Us /Va 014-
PLUMBING MECHANICAL TANKI
I DEMOLITION I I
DETAIL THE SCOPE OF WORK: Z4sr.4LL- (4"i0rL4&)%_ WWr TO -6W-i:ft10,L
vr e-4
RE07 OW & IFL&tr�L K. PO I ar 6VoTWrZ- /-ItOT4r�5- A& Ir/
I declare under penalty ofpeyjury 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 Name: joje,0AI /4,4,Wrj A/ Owner 0 Agent/Other [?f (specify):
Signature: Date: V-�-?&
FORM C LABuilding New Folder 2010\130NE & x-ferred to LBuilding-New drive\Fortn C 2014.docx Updated: 1/17/2014
REAM
Type of Gas/Air/Vacuum System (new and relocated)
Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical — Surgical Vacuum
Other:
I TOTAL OUTLETS
TANK #1
TANK #2
Method of Abandonment
Method of Abandonment
Fill in PlaceE] Fill Material
—
TFill in Place 0
Fill Material
Removal F-I
Removal El
Number of Gallons:
Number of Gallons:
Critical Areas Determination: Study RequiredE]
Conditional WaiverE]
Waiver 0
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 Conditional Waiver F1 Waiver
PSCAA Case No.
AHERA Survey done? (required) F-I
Additional comments:
FORM C LABuilding New Folder 20101DONE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014