20170811164915.pdf00/20
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 SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
JAIIte�,b000
& 9N61
Parcel #:
' 001
1,
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes F] No
Associated Permit #:
APPLICANT:
InIn �biz)
Phone: T
E7_
Address ree 7,
1KI(St t Cit State, Zi
3 ax' t-A e o
F ail �ddress:
ire? if 5 0 j;? M 4" La
PROPERTY OWNER:
Phone:
Fax:
Address (Street, City, State, tip):
Qpap'k 51st'A'le W
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR: MM
Phone: y)
Fax:
Address (Street, City, State, Zip):
I%lo3 6--_2(96 &C(M,�P27d_ 111A <?505A
E-Mai]�Address:
&Y2 5
*Contractor must have a valid City ofEdmonds business license prior to doing work
in the City. Contact the City Clerk's Office at 425.775.2525
FOR
WA State License #/Exp. Date:
" I "'; 9), 7 9,/ 5 9, 5 s 6 1/ �/Q Y// 2
City Business License #/Exp. Date:
PERMIT -kPPLICAITON
I PLUMBING I I MECHANICAL h(j TANK I
I DEMOLITION I I
DETAIL THE SCOPE OF WORK: dew A4!�'c Ileco, Pq/�7"e
Ideclare underpenalty ofperjury laws that the information Ihaveprovided on thisformlapplication is true, correct andeomplete,
and thatIant theproperty owner or duly authorized agent of theproperty owner to submit apermit application to the City of
Edmonds.
Print Name: Owner El Agent/Other (specify):
Signature: Date:
FORM C L:\BUfLDfNG DIVISION FILES\DONE & x-ferred to L-Building-New drive\Fonn C 2014.docx Updated: 1/17/2014
PLUMBING
FIXTURE COUNT oil
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
N
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? YesE] NoE]
HydronicHeatin: Floor 0 Wall E]
Floor Drain/Floor Sink
Other:
Refrigerator water Supply (for water/ice dispenser)
Other:
I
N/IECT1.ANIC,XL
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec Other:— #__L BTUs: <100k— >100k— Location(s)
Air Handler / VAV
(circle selected)
Gas # Flee # Other: # CFM: <10k >10k Location(s)
AC / Compressor
Boiler / Heat Pump
Gas #—Elec # Other:-- #— BTUs: <100k, _100k-500k, 500k-lMil
Roof Top Unit
HP: <3, __1_3-15, 15-30 Location(s)
(circle selected)
Hydronic Heating
Gas #—Elec #—In-Floor —Wall Radiant— Boiler BTUs: Location
Exhaust Fans (single
duct)
Bath # Kitchen # Laundry # _Other:
Fireplace
Gas #—Elec #—Other: # Location(s)
Dryer Duct
FUEL GAS
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
FORM C L:\BUILDING DIVISION FILES\DONE & x-ferred to L-Building-New drive\Fonu C 2014.docx Updated: 1/17/2014