20170508122153.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A 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 #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? YesE] NoE]
APPLICANT:
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Phone:
7- 0, 6 3 00 7 6
Fax:
Address (Street, City, State, Zip):
-7 "7'4*7 4z:�1-r-W
E-Mail Address:
1497� �S A-51111-k (,Via
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PROPERTY OWNER-,,
Phone:
Fax:
— -,::Z- vx�
I
Address (Street, City, State, Zip):
E-Mail Address:
:Z:F2 7— 1 1-7-2 ,j 4-
LENDING A�,fENCY: *
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
Phone:
Fax:
I O�c-
Address Street, City, State, Zip):
eloo-33
E-Mail Address:
A-1 L�I/A
*Contractor must have a valid City of Edmonds business license prior to doing work
WA State License #/Exp. Date:
".
7 , Al--WW 0 7 7C t—(
City Business License #/Exp. Date:
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C ty us
in the City. Contact the City Clerk's Office at 425.775.2525
IN
PLUMBING 1 �4 MECHANICAL TANK 6j.."LITION
DETAIL THE SCOPE OF WORK: C, Q /4
Ain tAe,�- .1 1_21,5!�e,&�
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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.
Print Name: Owner 0 Agent/Other 2e(specify):
Signature: Date:
sA,k
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FORM C LABuilding New Folder 2010\130NE & x-ferred to LAuilding-New drive\Form C 2014.doex Updated: 1/17/2014
PIAMBING
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 (�.g. RBPA, DCDA, AVB)
Water Heater Tankless? YesE] Noo
Hydronic Heat in: FloorE] WalIE]
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
RA
I DKIN r,
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elee
#
Other:— # BTUs: <100k— >100k—
Location(s)
Air Handler / VAV
(circle selected)
Gas #—Elec
#—Other:—
# CFNI: <10k— >10k—
Location(s)
AC / Compressor
Boiler / Heat Pump
Roof Top Unit
(circle selected)
Gas #—Elec
HP:
#—Other:—
<3,-3-15,
#_ BTUs:—<100k,
15-30 Location(s)
100k-500k, _500k-IMil
Hydronic Heating
Gas #—Elec
#—In-Floor
—Wall Radiant— Boiler BTUs:
Location
Exhaust Fans (single
duct)
Bath #—Kitchen
#—Laundry # —Other:
#
Fireplace
Gas #—Elec
#—Other:
Location(s)
Dryer Duct
I
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\DONE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014