20170503104334.pdfMay 03 17, 07:59a
TANKS BY DALLAS
206-361-0992
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Citv of Edmonds
DEVELOPMENT SERVrCES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5'h Avenue N, Edmonds, NVA 98020
Phane 425.7 71.0220 11 Fax 425.77 1.0221
PLE4 SE REFER TO THE PLUMBING & AfECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite City State, Zip):
Parcel
s,
C/
Associated Permit
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No
APPLICANT:
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Phone:
_01
Fax:
FL,
Address (Street, City, State, Zip):
E-Mail Address:
-5
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PROPERTY OWNER:
Phone:
Fax:
00
Address (Streer. City, State, Zip):
E-Mail Address:
ZZ
0INNING AGENCY--
Phone:
Fax:
I —
Address (Street., City, SLate, Zip):
E-Mail Address:
(:0. JTRACTOR:*
Phone:
Fax:
Address (Street, Cif,�, State, Zip):
E-Mail Address:
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WA State Lice9se #/E-xp. Date: S
"Contractor inusi have a valid Cit-�, of Edmonds business license prior to doing work
in the Ci�y. Contact the City Clerk's Office at 425.775.2525
City Business 11cense #/Exp. Date:
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PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK:
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I declare underpenaly ofperjury laws that the information I haveprovided on this jormlapplication is true, correct and complete,
and that I arn the property, owner or duty ataherized agent of theproperty owner to submit a permit appUcation to the City of
Edmonds.
�,'Print Name: Owner Agent/Other ��(.Specif-y)-
"Silmature: Date:
FORM C 1-:13uilding New Folder 20 1 WDONE & X-ferred to. L-Building New drive\Forrn C 2014.doex Upda-ted: 1/17!2014
May 03 17, 08:00a TANKS BY DALLAS 206-361-0992 p.3
GAS. AIR. VACUUM
INIEDICAL
Type of Gas/AiriVacuum System (new and relocated)
Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical - Surgical Vacuum
Other:
TOTAL OUTLETS
TANK #1
LN
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TANK #2
Method of kbandonment
Method of Abandonment
Fill in Place Fill Material f
Fill in PlaceE]
Fill Material
Removal
Removal El
Number of Gallons:
Number of Gallons:
Critic I Areas Determination: Study Required
Conditional Waiver 0
Waiver E]
Type of structure to be demolished (e.g. house, shed, garage, etc.);
Floor area of structure to be demolished: :L- sq. ft.
Critical Areas Determination: Study Required Conditional Waiver Waiver
PSCAA Case No. RA Survey done? (required) El
I AHF
Additional comments:
FORM C LABuIlding New Folder 2010\DONE & x-ferred to L Building -New dlive�Forrn C 2014.docx Undatrd. 1/17,'2014