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CITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDS, WA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
STATUS: ISSUED 06/02/2017 Pern&4:13LD20170741
Expiration Date: 12/01/2017 Projvct kthimss: 203 19 921NDA� E W, EDMONDS
Parcel No: 00506700000804
BETH BURROWS PLUMBERS CO-OPERATIVE PLUMBER'S CO-OPERATIVE
20319 92ND AVENUE WEST C/O THOMAS VEATCH C/O THOMAS VEATCH
EDMONDS, WA 98020 PO BOX 75355 PO BOX 75355
SEATTLE, WA 98175 SEATTLE, WA 98175
(425) 775-5383 (206) 858-2633 (206) 858-2633
LICENSE #: Qlumbe*8622h EXPJ 0/08/2018
,JOB DF-S('RIPTION
LEAKDIAGNOSIS &REPAIRAND/ OR REPLACE METER TO HOUSE. INSTALL ISOLATION VALVE AT HOUSE.
VALUATION: $0.00
PERMIT TYPE: Residential
PERMIT GROUP: 47 - Plumbing
GRADING: N CYDS: 0
TYPE OF CONSTRUCTION
RETAINING WALL ROCKERY
OCCUPANT GROUP:
OCCUPANT LOAD
FENCE: OXO FT-)
CODE: 2015
OTHER: ------- OTHER DESC:
ZONE:
NUMBER OF STORIES: 0
VESTED DATE -
NUMBER OF DWELLING UNITS: 0
LOT 4:
BASEMENT: 0 1 ST FLOOR: 0 2ND FLOOR: 0
BASEMENT: 0 1 ST FLOOR: 0 2ND FLOOR: 0
,3RD FLOOR: 0 GARAGE: 0 DECK: 0 OTHER: 0
3RD FLOOR 0 GARAGE: 0 DECK: 0 OTHER: 0
I BEDROOMS: 0 BATHROOMS: 0
IBEDROOMS: 0 BATHROOMS: 0
FRONTSFrBACK Si[)FSFFBA('k REAR SFrBACK
REQUIRED: PROPOSED: IREQUIRED: PROPOSED: REQUIRED: PROPOSED:
HEIGHT ALLOWED:O PROPOSED:O IREQUIRED: PROPOSED:
SETBACK NOTES:
I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUCTION AND IN DOINGTHE WORK AUTHORIZED
THEREBY, NO PERSON WILL BE EMPLOYED IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATINGTO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18 27.
THIS APPLICATION IS N0,r-A/P1'.RMIT UNTIL SIGNED BY T 1-11� BUI L.Dfti OVFICIAL OR I IISI[IFR DEPUTY AND ALL FEES ARE PAID.
WEN111- VIM x"A'A' 19050" N we, ?wca #6
Print
By
Date
ATTENTION
ITIS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF
OCCUPANCY HAS BEEN GRANTED. UBC1091 IBC1 10/ IRCI 10.
ONLINE APPLICANT ASSESSOR OTHER
-4
DEVELOPMENT 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, S te #, City State, Zip):
Parcel #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? YesE] Nok
APPLICANT:
L"�, W\ �L C 1"5 (0 - 0
Phone:
331
Fax:
Address (Street, City, State, Zip):
-1
dd
E -Mai A ress:
0'
k o1A KK Mi
e
PROPERTY ()WNER-
(9 a V1, LA) ">
Phone:
4D,572_4'�;W3
Fax:
Address (Street, City, State , Zip):
E-Mail Addres�:
A-10 c,,/O—
an �' 5 1_ 0 rA
LENDING AGENCY:
Phone:
Lhx:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR-*
"I
Phone:
Fax:
I
SE�� _� ( &
Address (Street, City, State,Zip):
E-Mail Address:
WA state LicenseXExp. Dle:
*Contractor must have a valid City of Edmonds business license prior to doing work
tLWuf AaRR
CILV Business License #/Exp. Date:
AN- OaqLO&
in the City. Contact the City Clerk's Office at 425.775.2525
� N a N LTA I I WAI N N M LWAV I M M
PLUMBING MECHANICAL TANKI
I DEMOLITION
DETAIL THE SCOPE OF WORK:
�Ij
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 propeny owner or duly authorize ent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: Owner[--] A e YOther (specify):
g7u�' X
-It�)
Signature:_TV_41MG(5 C Date: NJ! 4�i� I&
�dw
FORMC LAB ui ldi ng New Folder 201 0\130NE & x-ferred to L,13 ui ldi ng- New dri ve\Form C 2014.doex Updated: 1/17/2014
PLUMBING
FIXTU RE 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 (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes E] NoE]
Hydronic Heat in: FloorE] WallE]
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
Equipment Type
MLIJIMN-1�
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—Other:—
# BTUs: <100k— >100k--
Location(s)
Air Handier / VAV
Gas #—Elee
#—Other:—
# CFM: <10k— >10k—
Location(s)
(circle selected)
AC / Compressor
Boiler / Heat Pump
Gas # —
Elec #—Other:—
#_ BTUs:—<100k,
100k-500k, 500k-1Mil
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 L
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
I TOTAL OUTLETS
FORMC LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.doex Updated: 1/17/2014
GAS, AIR, VACUUM
MEDICAL
Type of Gas/Air/Vacuum System (new and relocated)
Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical — Surgical Vacuum
Other:
ITOTAL OUTLETS
TANK #1
M��
M �
TANK #2
Method of Abandonment
Method of Abandonment
Fill in Place Fill Material
Fill in PlaceEl
Fill Material
Removal
Removal
Number of Gallons:
Number of Gallons:
Critical Areas Determination: Study Required
Conditional WaiverE]
Waiver El
Type of structure to be demolished (e.g. house, shed, garage, etc.):
Floor area of structure to be demolished: sq. ft.
Critical Areas Determination: Study RequiredE] Conditional Waiver 0 WaiverEj
PSCAA Case No.
AHERA Survey done? (required)
Additional comments:
FORMC LABuilding New Folder 201000NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014