20170706091347.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5'h Avenue N, Edmonds, WA 98020
Phone 425.771,0220 9 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? YesEj No�
APPLICANT:
U— tis Lne WO/2- LLL
Phone:
H751 tf01;&.(0/
ax:
Ifol-
Address (Street, City, State, Zip):
E-Mail Address:
-70-�j s-r &v,/ /i_ 8o4
r , - k (P e- Al o e- k -Sj cv, I
PROPERTY OWNER:
Phone:
IT-71 --LIT
Fax:
Address (Street, City, State, Zip): 0%
MH 1`12 5 Ave NF- Z 4.j 43,8 a3 Lf
E-Mail Address:
J L.--)'l I t 12 e, �,00- L_,� .1,
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
91,je4&7 UJOAC, LLC_
Phone:
Fax:
Address (Street, City, State, Zip):
-7 031 7-Zo"- 5-1 A4 L-T L-,A- fl30K�;p
E-Mail Address:
1AF0 P 0�0e.,-11100
.9
*Contractor must have a valid City of Edmonds business license prior to doing work
WA State License #/Exp Date -
G tq FZ (�,_ Vl L 6�3 j�� ig /1 -1
City Business License #/Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
I b Z 11
111-NMI'l AITLICATION FOR
PLUMBING ME HANI ANK DEMOLIT
DETAIL THE SCOPE OF WORK: WA-1 e�_e_
C-1u, ^!) e
s ii-e- e (L S-T Ot,-J j Kj L_c> N e
.9
I declare und r pen ofperjury laws that the information I have provided on this formlapplication is true, correct and comp ete,
and that I am I e p o erly owner or duly authorized agent of the property owner to submit a permit application to the City of
Edmonds.
/A
Print Name: L.", Owner�$Agent/OthcrEl (specify):
Signature: Date: -71(a 1 :7
4e
L.-I - N111i
FORMC LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014
MA
PLUMBING
FIXTURE COUNT
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
Pressure Reduction Valve/Pressure Regulator
Sink (Idtchen, 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 El No LP
Hydronic Heat in: Floor E] Wall E]
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
I
DIN 1111110 1 LWR =
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #_LElec
#—Other:
_#
BTUs: <100k >100k—
Location(s)
Air Handier / VAV
(circle selected)
Gas #—Elec
#—Other:—
#_CFM: <10k— >10k—
Location(s)
AC / Compressor
Boiler / Heat Pump
Roof Top Unit
(circle selected)
Gas #—Elec
HP:
#
<3,-3-15,
Other:—
15-30
#_ BTUs:—<100k,
Location(s)
100k-500k, 500k-Mil
Hydronic Heating
Gas #—Elec
#—In-Floor
—Wall Radiant— Boiler BTUs:
Location
Exhaust Fans (single
duct)
Bath #—Kitchen
#—Laundry #
—Other:
#
Fireplace
Gas #—Eiec
#—Other:—
# Location(s)
Dryer Duct
I
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 BBQ
I TOTAL OUTLETS
FORMC LABuilding New Folder 201000NE & x-ferred to L-Building-New drive\Forin C 2014.docx Updated: 1/17/2014