20170803083557.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
es t. S 121 5'h 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 SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
726 (a-H4 /4 ge 5,
27634500?-0cf',70
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes NoO
Associated Permit #:
APPLICANT
�r_7-hlw A 4>me 14 A401"AVIJ 4k;1V.Q le
Phone:
412S 970 99 7&
Fax:
Address (Street, City, S%te, Zip):
E-Mail Address:
Ah AVK1P_44_ 191A(
31 Ye '?!?2jg-5 S'
PRQIIERTY OWNER:
j0hA) WW545
Phone-
qZIS '7 25092_6Y
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
7 1, 1,;f*\ mve S., a-eeld
LENDING AGENCY: W/11-/
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR-*
A-00,4;z
Phone:
L7��S
Fax:
41vh
Address (Str et, City, State, Zip): '
; 46 1-- ;,1V V*2720
E-Moll Addre s:
. es
M, jl��,OJAArVAOAW,
WA State . ense /Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
'C' ,4() q_ q 10.
f
City Bus*ngs License #./Exp. Date:
b'?,-tl Pq -7
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING MECHANICAL TANKI
I DEMOLITION
DETAIL THE SCOPE OF WORK: FYiSjAVj WWkf IiAle- F.WoO &AWW -IV /2005C.,
1r lank
ZZW 6184VIX4 IV 6;f 1164 Alle & 0 40-
I
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: lZaou 9-ei A/Z— Owner F-1 Agent/Other;e(specify): 4t>A6yYCk1'
Signature: :!::2: Date:
L_ zl�
FORMC LABuilding New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.doex Updated: 1/17/2014
PLUMBING
Fixture Type (new and relocated)
Total #
FIXTURE COUNT
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 NoE]
Hydronic Heat in: Floor Wall
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—
Locatioii(s)
Air Handler / 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
#_Othcr:_
# 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
Other:
Fireplace/Insert
Stove/Range/Oven
Dryer
BTUs: Location(s):-
BTUs: Location(s):-
BTUs: Location(s):-
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\130NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014