20170524161812.pdf`BLD,_�Lo [7 - C(o IC
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITIONRECEIVE
D
PERMIT APPLICATION
is 1215 1h Avenue N, Edmonds, WA 98020 MAY 0 5 ?0 17
City of Edmonds Phone 425.771.0220 R Fax 425.771.0221 DEVELOPMENT ISFRVInin
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
IQ4 1,19_e44el
_73(o0c)�;--00&12
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No
K
-Associated Permit #:
APPLICANT-
441�
Phone: &OW&
1, - 6
I iax:
0 J, q,- 63
jr/o
Address (Street, Cit tate, Zip):
I VC-d-7
E-Mail Address -
opaj4&
Pit
,QPERTY OWNER-
Ge 04X44� - `�Ie� -
Phone:
Fax:
I
Address (Street, ity-S Z'
r
E-Mail Address:
LENDI��NCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
Alk�&,014 01-013111-
Phone;,2�6
6>83 3 S2 ? T131
Fax- -.3—'
Address (Street, City, State, Zip),
01
E-Mail Add s:
XT= kJ,..
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W,A State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
6��S&k W�T7 3L 41�
in the City. Contact the City Clerk's Office at 425.775.25?1 Cr 19 i..R
ILI 10—
ty F s License C.
lusines
PFRMH APPLICATION FOR
PLUMBING I MECHANICAL I TANK
DEMOLITION
DETAIL THE SCOPE OF WORK: ez",6—
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I declare under penalty ofperjury laws that the in rmation 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 [� �Agent/Othe El (specify):
Signature: Date:
////V
� eA.,
6-cle
FORMC LABuilding New Folder 2010\130NE & x-ferred to LBuilding-New drive\FormC 2014.docx Updated: 1/17/2014
MEDICAL GAS, AIR, VA(-UtJM
Type of Gas/Air/Vacuum System (new and relocated)
Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical — Surgical Vacuum
Other:
I TOTAL OUTLETS
TANK #1
TANK #2
Method of Abandonment
Method of Abandonment
Fill in Place Fill Material
Fill in PlaceEl Fill Material
Removal
Removal F—I
Number of Gallons: 15:—v C)
Number of Gallons:
Critical Areas Determination: Study RequiredEj Conditional Waiver 0 Waiver F-I
���I I �I
Type of structure to be demolished (e.g. house, shed, garage, etc.):
Floor area of structure to be demolished: sq.
Critical Areas Determination: Study Required El Conditional WaiverE] Waiver 0
PSCAA Case No.
AHERA Survey done? (required)
Additional comments:
FORMC LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014
ED
CITY OF EDMONDS
121 5TH AVENUE NORTH -EDMONDS, WA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
BUILDING APPLICATION ACCEPTANCE
Friday, May 05, 2017
This Application has been accepted by the City of Edmonds for review. More information and changes
may be required during this process. The review target date is: Friday, May 19, 2017
Your City Contact is:
LINDA THORNQUIST
Application Number: BLD2017061 0
Project Address: 21 Oil HILLCREST PL, EDMONDS
PROPERT)'OWNER APPLICANT
BEVERLY A & STEVEN T FRANKLIN CASCADE WEST TANK SERVICES
FRANKLIN STEVEN T 18527 28TH AVE NE
21011 HILLCREST PLACE LK FOREST PK, WA 98155
EDMONDS, WA 98026 (206) 683-3599
(206) 946-6910
Work Description:
PUMP, RINSE AND REMOVE UST
Outstanding Items at Time of Submittal:
It is anticipated that the following departments will be reviewing your application:
El Building
[I Planning
[I Engineering
L Fire
11
Please wait to re -submit corrections until after you have received comments from all reviewing
departments.
III ERP'YATCKNOW LEDGE THAT I HAVE READ THIS APPLICATION THAT THE INFO RMATIO N GIVEN IS CORRECT
I M THE PROPERTY OWNER, OR THE DULY AUTHORIZED AGENT OF THEPROPERTY OWNER T10
,(%Iy THA A
SUBMITABUILD ;PERMIT APPLICATIO N TO THE CITY.
S - I QKX V)k E (d4' N ER 0 R A G EN T) PRINTNAME DATESIGNED
To view up to date information aboutyour application please visit the City ofEdmonds Development Services
website at http.,Ilwww.ednwndswa.gov.
Bid Sheet
Date Name—v-.-�, - V��
Address
Phone# E
Vacant Pets owner?
Tank Location P-I.A4,t- S$/
�-c� Fill pipe above grade
Agent
Total Depth Fill Pipe Diameter
Contents Oil U7�� Water Other
ej
Field Notes
114 C 90 s,
Office Notes
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RECEI ED
MAY 0 5 TI 7
DEVELOPMENT 3
GOUNTEJ RVICES