20170609105835.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
1215 1h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 It 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 #:
;?_j 0 1+ -11-0 ft, 4 F_ VAA0NDe;,, 0 A I bo 2_(q
co �5 it 4" oc000 100
�
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No WSJ
Associated Permit #:
APPLICANT:
4--f [:—: [714�_N AA14;CVAK
Phone:
lo+-OG'A5 _,
Fax:
Address (Street, City, State, Zip):
-7qTH PAJoN VvA t) U,
E-Mail Address:
qeAA 15CW K I q 8 044� IL_
1-4-o 14- 12L W E- L75
PROPERTY OWNE
e7-fr-_?Het,�
Phone:
I A (0 (�; - (4 _W
Fax:
I
Address (Street, City, State, Zip): 61 SC)�$
,Z4-r214 11 -T14 r L_ W
E-Mail Address: 66011_X�
<ZMK(1
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
APVANCLO 1W7TAUA,-[1oi,4
PhQne:
+171r;7- . 6q_11T
Fax:
Address (Street, City, State, Zipj:
1&6D+ LlVq PI 1j, V\jlk IiFO�31
E-Mail Address:
Apyi-0-AWANCEPIN51A"110A - �J;T
WA State License xp. at
*Contractor must have a valid City of Edmonds business license prior to doing work
Af2VA ,�9 (A S1 Im
in the City. Contact the City Clerk's Office at 425.775.2525
Ntz — 022?10CL
City Business License #/Exp.' atd:
ITIM] APPLICATION FOR
PLUMBING I I MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK: AwV
AALCHANKAL FOR
[We�-TAL/LjLjiN uF 6 IRANI< (N DALI P164 U(a
&j?cot4<MW &N�
MROM(L INK-F-KI - All-60i &64 BFING' QM
I C-70-R FlA-rL41ZFI
I declare underpenalty 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: -:f7—CC— ki K"AK- OwrierRrAgent/OtherEl (specify):
Signature: Date:
FORM C LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.docx 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.)
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] Wall E]
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
I
Fu I
Equipment Type
�
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
#—Offien—
#— 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 #—LElec #—Olber:
--
# Locatioii(s) LAN�z
ROOM
Dryer Duct
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 ISH
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.doex Updated: 1/17/2014