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-�: PLUMBING, MECHANICAL, TANK, & DEMOLITION. cS
PERMIT APPLICATION i
121 5"' Avenue N, Edmonds, WA 98020
Phone 425.771,02201Q Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): B�Zo
Parcel #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
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APPLICANT:
BA14 K .AMA �- "A
Phone:
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Fax:
Address (Street, City, State, Zi ):
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Mail Address:
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PROPERTY OWNER:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
.ENI G AGENCY:
Phone:
Fax:
A dress (Street, City, State, Zip):
E-Mail Address:
CON RA TOR•*
Phone:
Fax:
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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 TANK
DEMOLITION
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DETAIL THE SCOPE OF WORK: L `
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I declare under penalty of perjury laws that the information I have provided on this form/application rs 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:_ r O��✓ OwnerofAgent/Other ❑ (specify):
Signature: - -s Date:
FORM C LABuilding New Folder 201000NE & x-ferred to L-Building-New drive\Form C 2014.doex Updated: 1/17/2014