20170509102147.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5h Avenue N, Edmonds, WA 98020
Phone 425.771.0220!& Fax 425.771.0221
City of Edmonds
P SE RF4EER 70-THE PLUMBING& MECHANICAL CHECKLIST FOR SUBMI77AL REQUIREMENTS
OL
44
T
4
r . 4 V I I
PROJECT ADDRESS (Street, Suite #, City State, Zip):
-2-al
Parcel #:
?2 qt�
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? YesE] No[N
Associated Permit #:
APPLICANT:
AL
Phony- Fax:
Address S cetrCity, Staig. Zip)-
0 1 K - L, _07 1-414de'tl zuA
E-Mail Addiess-
7-
V OWNER:
/7LA.A) A*�_"
Phone:
Fax:
I
-
)reel, City, State, Zi
Address (S p):
2 A;/� 5�
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
Z;)
Phone:
Fax:
A ess (Street, City S Zip)- V
Ar
_Y11-16 ;r_- 't) Z_
J_
E-Mail Address:
*Contractor must have a valid City of Edmonds business license prior to doing work
in the City. Contact the City Clerk's Office at 425.775.2525
WA Stal6 License #/E D-
Cit�Busmne�,glicf-.nse.#/Exp.Dite:
�UNEALVAII NUM[WIVEMOMim
PLUMBING MECHANICA TANKI
I DEMOLITION I
DETAIL THE SCOPE OF WORK:
L�s _1 0� i=10-e Z- _S�
%,— —
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 tAgent/Other 0 (specify):
Signature: Af_Q — Date:
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New driveTorm C 2014.docx Updated: 1/17/2014
PLUMBING
FIXTURE COLNT
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 No
Hydronic Heat in: FloorE] Wall E]
Floor Drain/Floor Sink
Other: <�;"4 A
,�,v Z) 4
Refrigerator water supply (for water/ice dispenser)
Other:
Equipment Type
�KNIFIAIMWJ
Appliance/Equipment Information (new and relocated)
7
Furnace
Gas #_Elec
#_Other:_
# BTUs: <100k >100k—
Location(s)
Air Handler / VAV
(circle selected)
Gas #—Elec
#—Other:—
#—CFM: <10k— >10k—
Location(s)
AC / Compressor
Boiler / Heat Pump
Roof Top Unit
(circle selected)
Gas # —
HP:
Flee #—Other:—
<3,
#_ BTUs:—<100k,
_3-159 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
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 LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014