20170629120710.pdf-a L, 7 - 06 7 6
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J DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 51h Avenue N, Edmonds, WA 98020
Phone 425.771,0220 It Fax 425.771.0221
City of Edmonds
PLEASE, REFER TO THE, PLUMBING & MFCHAIVICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
I Ist (ACY-) CA()� & , WP Cis 020
00ff (P 12_000D 1 (00 1
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? YesE] No;)�
Associated Permit #:
APPLICANT:
_FCA V) �t n
Phone:
Fax:
2 OU - 3 __G ZeA 1
0 902
Address (Street, City, State, Zip):
i 5's Z A hpyes,-k
E-Mail Address: -Rt1A4,(j,
7 n I I V1 Vy aAt
V1 yl* 11) 11 /1 11-1, 1�
PROPERTY OWNER:
Phone: Fax:
(z' 11 Y14 - L4- 11 V1 -e—
42r)-71 3- 2
Address (Sire&. City, State, Zip).
7— 1 L-)Z;�� pj.tij &_CjM0
E-Mail Address:
K I i ae tjR V-!4 Zlco 1%, ra (, C1 5 + -
7ENDING AGENCY:
Phone: Y
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR-*
—ron 'al/as
Phone:
� (.�, 4) -1
W —
ax:
7 0 6 -0& f -C.
Address (Street, City, State, Zip):
E-Mail Address: la- il le S 6 td.
-7 Is 5 2- &11 ioae-K 1A A IF— L k - ft)jex-l- Pai-r_
-�av7tzsh-;ldd1jejy. rl-d*
WA State Licl�nse #/Exp. Date:
:I:Contractor must have a valid Cit ' v of Edmonds business license prior to doing wol*
'. 4*
-fa rl k-�s ,, 00 1 )4
City Business License #/Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
I Ai '113 2-(;( �Vj
PERMIT APPLICATION FOR
PLUMBING I MECHANICAL I TANK
DEMOLITION
DE TAIL THE SCOPE OF WORK: D y � n & e
wA +'10 'in DWU �:;()o nrilton- _11ST,
I declare underpenalty ofperjury laws that the information I have provided on this form/application 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 Cily of
Edmonds.
Print Name: C--,, H uucl Owner D Agent/Other W(specify):-Taii o 64Lk/ /ar
Signature: Date: 2911-7
�o 4
FORMC LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
IME YWA L GAS, AIR, VACUUM
Type of Gas/AirNacuum System (new and relocated)
- I
Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical - Surgical Vacuum
Other:
I TOTAL OUTLETS
TANK #1
77
TANK#2
Method of Abandonment
Method of Abandonment
Fill in Place Fill Material -'SOM <L
Fill in Place E]
Fill Material
Removal D
Removal 0
Number of Gallons:
Critical Areas Determination: Study Required
Number of Gallons:
Conditional Wai verE] Waiver
FORM C L:\Building New Folder 2010\DQNE & x-ferred to L-Building-New driveTorm C 2014.docx Updated: 1/t7/2014