20170411111342.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
1215 1h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJEC ? YesF] No;K
Associated Permit #:
APPLICANT:
Cro'-',
Phone:
Fax:
eve. \��— 9�,-c w",
A -Lc-.
Address (Street, City, State, Zip):
E-Mail Address-
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PROPERTY OWNER:
Phone: T
ax:
Address (Street, City, State, Zip):
E-Mail Address:
1��crl
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
E� Alg,
Phone:
47-5-3 4 c4or-1
ax:
I
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Address (Street, City, State, Zip):
S13 5i,,-TE 166— WA
E-Mail Address:
9 Y-,E:;S (c,
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
6 vc,-. ri-I A 9 (. P, M 7
City Business License #/Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
PHR M ITAPPLICA HON RM:
PLUMBING I MECHANICAL TANK�DEMOLITION
I
DETAIL THE SCOPE OF WORK:
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.
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Print Name: LAt-A FU0z!5LA-ktLEfz— Owner 0 Agent/10the �6 (specify):
4
Signature: Date:_4__1
FORMC LABuilding New Folder 2010\130NE & x-ferred to L-Building-New driveTorm C 2014.docx Updated: 1/17/2014
PLUNIRING
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 0 NoE]
Hydronic Heat in: Floor 0 WalIE]
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas # _LEJec #—Other:—
# i001ZTUs: <100k— >100k—
Location(s) �t 4,
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-IMil
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 #
#
duct)
—Other:
Fireplace
Gas #—Elec
#—Other:--#—
Location(s)
FDryer Duct
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 LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014