20170530113123.pdfLP 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, Zip):
Parcel #:
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Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? YesEj NoE]
APPLICANT:
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Fax:
Address (StrVt, Cit State, ZiE):
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E-Mail Address:
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PROPWY OWNER:
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Address (Street, City, State, Zip).
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E-Mail Address:
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LENDING AGENCY:
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ax:
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Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*1:::`�
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Phone:
Fax:
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Address (Street, City, State, Zip):
E-Mail Address:
WYtatc License #/Exp. Date:
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*Contractor must have a valid City of Edmonds business license prior to doing work-7)'
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City 13 si nes * . Date:
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in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING Vj' M CHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK: xzt,
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Ideclare underpenalty ofperjury laws thatthe information Ihaveprovidedon this jormlapplication istrue, correct and complete,
and that I am the property owner or duly authorized agent of the propeny owner to submit a permit application to the City of
Edmonds.
?6ZL-t4W( �Owner
PrintName: ��gent/Other (specify):
Signature: Date: h 0
FORMC LAB ui I ding New Folder 201 000N E & x-ferred to LB uj I di ng-New dri ve\Form C 2014.doex Updated: 1/17/2014
PLUMBING
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.)
Z
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: FloorE] WalIE]
Floor Drain/Floor Sink
Qdwr--
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 Handler / VAV
Gas #—Elec
#—Other:—
# CFM: <10k— >10k—
Location(s)
(circle selected)
AC / Compressor
Boiler / Heat Pump
Gas #—Elec
k__0thcr:_
# BTUs: 100k,
100k-500k, 500k-IMil
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 __F_
in DI
Appliance Type
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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
FORMC L\Buflding New Folder 2010\DONE & x-ferred to LBuflding-New drive\Form C 2014.docx Updated: 1/17/2014