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Y N DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5'' Avenue N, Edmonds, WA 98020
�St l �qo Phone 425.771.0220 4 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PL UMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS Street, Suite #, City State, Zip):
Parcel #:
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Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ Noo
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APPLICANT:
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LENDING AGENCY:
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Fax:
Address (Street, City, State, Zip):
E-Mail Address:
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must have a valid City of Edmonds business license prior to doing work
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City Business License #/Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK:-2
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.�&4Print CX17t4
Name: 1 C1 tr Owner ❑ ent/ ther (specify): cj' )x—
Signature: Date:
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FORM C L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form 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 ❑ No ❑
Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
MECHANICAL
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
# Other:
# BTUs: <100k >100#
Location(s)
Air Handler / VAV
Gas #
Elec #Other:
# CFM: <10k >10k
Location(s)
I
(circle selected)
—
—
AC / Compressor /
Boiler / Heat Pump /
Gas #_Elec
#_Other: _
#— BTUs: <100k,
100k-500k, 500k-1Mil
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
FUEL GAS
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: Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\130NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014