20170526142409.pdfAl
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5'h 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 ZZi
S5 C 7, _00 Sq
I
Parcel #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes E No F71
Associated Permit #:
APPLICANT:
14-e � di Nlt"
Phone:
q2,5--7_78�'0a&q1
Fax:
Address (Street, City, State, Zip):
Sq 10 C1
E-Mail Address:
np--+ -�+esl-1 at Ile) fim
PROPERTY OWKTi7V %
,I tt -s
Phone:
5!x VV02-
Fax:
I
Address (Street, City, State, Zip):
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
'Sa c,�.&Ar
L L
Phone:
,;�0(0
Fax:
Address (Street, City, State, Zip):
30 q q
E -Mail Address:
5.")e_VAViM4Lj,
*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 State License #/Exp. Date:
City Business License #/Exp. Date:
PLUMBING I I MECHANICAL TANKI
I DEMOLITION 66
DETAIL THE SCOPE OF WORK: A
4C)"
U
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: S Ownegr Agent/Other El (specify):
Date:
Signature. 02
N_
FORMC LAB ui I ding New Folder 201 O\DONE & x-feTred to L-B ui Iding-New dri ve\Fo rm C 2014. docx Updated: 1/17/2014
M PLUMBING
Fixture Type (new and relocated)
Total #
FIXTURE COUNT
Fixture Type (new and relocated)
0
Totalr
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? YesE] No E]
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 #—Elec
#
Other:— # BTUs: <100k >100k—
Location(s)
Air Handier / VAV
Gas #—Elec
#
Other:— #—CFM: <10k >10k—
Location(s)
(circle selected)
AC / Compressor
Boiler / Heat Pump
Gas #—Elec
#—Other:—
#_ BTUs:—<100k,
100k-500k, _500k-lMil
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 # —Other:
#
duct)
Fireplace
Gas #_Elec
#
Other: # Location(s)
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s):
Furnace
BTUs: Location(s):-
Water Heate
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\130NE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014