20170816110845.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 9 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 #:
7,506 1-WAd--me-9_ D�2_
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? YesE] No E]
APPLICANT
LT-&IFAASoc.�4ge <;epvrc rs LLC--
.-c
Phone:
q7 J&
-s-.s- -L/V�
Fax:
Address (Street, City, State, Zip): Vt/
133*3o MA4e- A f_-C AJ WATTI.0
E-Mail Address:
PROPERTY OWNER:
Phone:
Fax:
Address (Street, City, State, Zip):
75-be 99-hc-ow-9- DIL
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
Phone-
Fax:
Address (Street. City. State, Zip):
13336 _y-ta4/&r %W13
E-Mail Address:
*Contractor must have a valid City of Edmonds business license prior to doing work
WA State License #/Ex Date:
z4fKASC87jPd.,�-
City Business Li COCA Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
4
PLUMBING MECHANICAL TANKI
I DEMOLITION
DETAIL THE SCOPE OF WORK:
I declare underpenalty ofperjury laws that the information I haveprovided on this formlapplication is true, correct and complete,
and that I am the proper1y owner or duly authorized agent of the propeny owner to submit a permit application to the City of
Edmonds.
Print Name: Owner D Agent/Other EX(specify):
Signatur Date:
VA
FORMC LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
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.)7
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] No
Hydronic Heat in: Floor WaIIE]
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
�A I DIN I R101 LWAII �
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—Other:—
# BTUs: <100k— >100k—
Location(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-lMil
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
I
I Ll
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 LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.doex Updated: 1/17/2014