20170725111945.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5'11 Avenue N, Edmonds, WA 98020
Phone 425.771.0220 2 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 #:
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Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT: ljov„r\^_ C�ou_wr V( v w4ok � I Phone: Fax;
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Address (Street, City, State, Zip): 1 0 t;,*j -I, o_ Nip- W E-Mail Address.
PR11 OPERTY OWNER: 'SQ�'���- Phone: Fax:
Address (Street, City, State, Zip): - '5+A-, pL E-Mail Address:
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LENDING AGENCY: Phone: Fax:
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Address (Street, City, State, Zip): E-Mail Address„
CONTRACTOR:* �j-j�,� (�t� ni�\ua„� �,,,� Phone: Fax.
2S" 7 7 7 �3-7 7
Address (Street, City„ State, Zip): kc&oQ) `7(v- ,, � E-Mail Addrem
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WA State License #/Exp. Date;
*Contractor must have a valid City of Edmonds business license prior to doing work c,( \VT D3o'?
in the City. Contact the City Clerk's Office at 425.775.2525 ("It Business License #/Exp. Date: tssu` �
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PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK:...... . .. � _...... � "'�...... : � s
,�... [` m __....._ .........
I declare under penalty of perjury laws that the information I have provided on this form/application is true, correct and complete,
and that I ant the property owner or duly authorized agent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: �" � 5 0.------- .a... ...�... .. Owner ❑ Agent/Other (specify):
m,. .. _ ..
RN
Date
Signature:
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
PLUMBINGF
Fixture Type (new and relocated)
Total #
IRE COUNT
Fixture Type (new and relocated)
Total #
fWater Closet (Toilet)
Pressure Reduction Valve/Pressure Regulator
_................
m....... ..,.w....
(kitchen, laundry, lavatory, bar, eye wash, etc.)
a ._ .....
Water Service Lthe
I
Tub/Shower
Drinking Fountain
Dishwasher
Clothes Washer
Hose Bib. -..... _.._
Backflow Prevention Device (e.g. aBPA, DCDA, AVB)
. ................................. ._.- ...... _---__-
Water Heater Tankless. Yes ❑ No ❑
Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink
Other:
Refrigerator water Wv_ .-----------�r
g supply (for water/ice dispenser)
Other:
nt Type
Appliance/Equipment Information (new and relocated)
Total #
FFurnace
Gas #_Elec
#_Other:
... # ......... BTUs: <100k_ >100k_
Location(s)„_
dler / VAV
Gas #
Elec #_Other:
# CFM: <10k_ >10k_
Location(s)_,,,-mmmmmmm,,,,,,,
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Gas #_Elec
#...................
Other: _ ................ # ........................ BTUs: <100k, _ ..........
_.._100k-500k, ....... ....._500k-1Mil
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/Equipment Information (new and relocated)
Total #
Appliance Type
AC Unit
BTUs:
�....� Location(s).�— ... .....
Furnace
BTUs:.
......._....
. . . . ....................
Water Heater
BTUs:
Location(s):, -_ ......
. .
Boiler
BTUs:
... ..�_ .... Location(s):_. _.. __._ ,, ,_,_ _...
Other: �.._..._..-.
BTUs:
Location(s): �� ....... ..........
Fireplace/Insert
.........
BTUs:
,,...,.., mm......
�.�..� - _� ... ..� �.......... __.... m
Stove/Range/Oven..._...
m..-.. ...... .m.- .........
.
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C 1-Mudding New Folder 2010\DONE & x-ferred to L-Building-New driveTorm C 2014.docx Updated: 1/17/2014