20170817114004.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
1215 1h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 It 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 #:
_210
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes [—] No ;4
Associated Permit #:
APPLICAN!A4
Phone -
Fax:
Ircs/et C. St Zi
6 �,;I_b t, W;y 5/" A�.2,0411
E-Mail Address:
TC> 1p" AJ P4 0 J4ge1_1,F
PROPEPfTY OWNER:
Fax:
A ress trect ty, t I
/U P�
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONT"CTOR *
t0kjM9/,-0g X,,/_ C
Phone:
Fax:
_7TPPr,,-U,:A)
AddressAStreet, City, State, Z'
E-M,3j'l Addre
5(�, 'Zi
*Contractor must have a valid City of Edmonds business license prior to doing work
in the City. Contact the City Clerk's Office at 425.775.2525
WA State License #/E 1)
City 13 usi nes5. License #51). Date:
PERMI'l APPLICATION F(M
PLUMBING I MECHANICAL I TANK I
DEMOLITION I I
DETAIL THE SCOPE OF WORK: If?4 eW c_-e-
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: 6:-- Owner �<Ageni/Othcr (specify):
Signature: Ir -y Date:
. 04__�
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Forill 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
Water Heater Tankless? Yes 0 No E]
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Hydronic Heat in: Floor Wall
Floor Drain/Floor Sink
Refrigerator water supply (for water/ice dispenser)
Other:
Other:
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 # _0(her:
#
duct)
Fireplace
Gas #—Elec
#—Other:
# Locatitni(s)
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s):
Furnace
BTUs: Location(s):-
Water Heate
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 1-Muilding New Folder 2010\DONE & x-ferred to LBuilding-New drive\Form C 2014.doex Updated: 1/17/2014