20170718153429.pdf" tp DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
1215 1h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBM17-TAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City,�tate, Zip):
Parcel #:
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Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes Noj�,
_Associated
APPLICANT:
P1
Fax:
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PROPERTY OWNE11'
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Phone:
Fax:
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E-Mail Address:
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LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR,,�*7—
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Phone-
266
Fax:
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E-Mail Address:
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WA State, LicenwN/Ext D,,Lt
*Contractor must have a valid City of Edmonds business license prior to doing work
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.Lccnse A!/ x Date:
"So"� - � 0�1
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING MECHANICA TANK
DEMOLITION
10� � C, 0 KI-CIN I 0111\ of (�Z)
DETAIL THE SCOPE OF WORK: &/I/
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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 property owner or duly authorized agent of the property owner to submit a permit application to the City of
Edmonds.
I Wspecifv): f Itlim �-�r ol%'o�
Print Name: Owner Agent/Other
Signature: t Date: Z-49—/
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FORMC LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New driveTorm 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? Yes E] NoE]
Hydronic Heat in: Floor E] WalIE]
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
L_
Other:
�kl I DIN I VA101 M1
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—Other:--
# BTUs: <100k_ >100k--
Location(s)--
Air Handier / VAV
Gas #—Elec
#—Other:—
#_CFM: <10k— >10k—
Location(s)
(circle selected)
AC / Compressor
Boiler / Heat Pump
Gas # —
Elec #—Other:—
— #_ 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 #—Elec
#—Other:—
# Location(s)
[Dryer Duct
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
TOTAL OUTLETS
FORMC LABuilding New Folder 2010WONE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014