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DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5h Avenue N, Edmonds, WA 98020
$1. 1%9 Phone 425.771.0220!k 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 #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes 0 No
APPLICANT: 1—�Z4
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Phone:
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Fax:
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Address (Street, City, State, Zip):
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E-Mail Address:
PROPERTY OWNER:
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Phone:
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Fax:
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Address (Street, City, State, Kip): Y-P2_0
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E-Mail Address:
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LENDING AGENCY:
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Phone:
Fax:
Address (Stifet, City, State, Zip): 6c) O�- Cr 'Y-
E-Mail Address:
CONTRACTOR:*
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Pholic: Fax:
Address (Street, City, State, Zip):
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E-Mail Address:
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WA State License #/E*p. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
siness License #/Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING MECHANICAL TANKI I DEMOLITION
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DETAIL THE SCOPE OF WORK:
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I declare under penalty of perjury 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.
PrintName: Owner 9 Agent/OtherEl (specify):
Signature: Date: 6 .7-01 L -7
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FORM C LABuilding New Folder 201 MONE & x-ferred to L-Bui Iding-New drive\Forin 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] NoE]
Hydronic Heat in: FloorE] WalIE]
Floor Drain/Floor Sink
Other: R�e_rl-c�e
Refrigerator water supply (for water/ice dispenser)
Other:
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Equipment Type
L1
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #_Elec
#_Other:_
# BTUs: <100k— >100k-- Location(s)
Air Handler / VAV
Gas #—Elec
#_O(her:_
CFM: <10k— >10k— Location(s)—
(circle selected)
AC / Compressor
'10'0k-500k,
Boiler / I I eat Pump
Gas# AElec
#—Other:—
BTUs:_<100k,24A 500k-1Mil
Roof Top Unit
HP:
<3,-3-15,
15-30
Location(s) r"t
(circle selected)
Hydronic Heating
Gas #—Elec
#—In-Floor
—Wall RadianL_ Boiler BTUs: Location
Exhaust Fans (single
Bath #
Kitchen # Laundry #
duct)
—Other:
Fireplace
Gas #—Elec
#
Other:—
#_ Loocation
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: -266,000 Location(s):
Other:
BTUs: Location(s):_
Fireplace/Insert
BTUs: Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORMC LABui [ding New Folder 201 MONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/t7/2014