20170727085314.pdf-.r-
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
1215 1h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A 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 #:
2oo ck,^&e_s qvio'n
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes E] Nov
Associated Permit #:
APPLICANT:
Phone:
4-4Z IC- - -7 -7 -�- - ?4
Fax:
A( ess (Stre 'ity, State, Zip): 3
11� "11
E-Mail Address:
t) LJX flil�, 0 F.S C.
PR,Q,PERTY OWNER:
�Q C-CL-0-k -K-, c!
Phone:
Fax:
I
Address (StrgaEf ity, State, Zip 4
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONT!��C 0
Phone:
2 37 -7 T
Fax:
A� ress (Street, City, State, Zip):
':ij?o2_L
E-Mail Address:
-7SLf
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
So Lcrk C-4 i�� "36:? vhajy
City Business License #/Exp Date -
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK: X, COWL
olo
k 1q, C:p V11, Cos.+- lro--
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.
Print Name: V, -k— \I. Owner [SAgent/Other D (specify):
Signatur������.. Date: -7
FORM C LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New driveTorin 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 (�.g. ROPA, DCDA, AVB)
Water Heater Tankless? Yes E] NoE]
Hydronic Heat in: Floor E] WallE]
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)_
Other:
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—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 # —
HP:
Elec #—Other:—
<3,
#— BTUs:—<100k,
—3-15, 15-30 Location(s)
100k-500k, —500k-IMil
Hydronic Heating
Gas #—Elec
#—In-Floor
—Wall Radiant Boiler BTUs:
Location
Exhaust Fans (single
duct)
Bath #—Kitchen
# Laundry # Other:
#
Fireplace
Gas #—Elec
#—Other:
# Localion(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
TOTAL OUTLETS
FORMC LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.docx Updated: 1/17/2014