20170824113252.pdf_ff
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5'h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 2 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
f
21" 7.
Parcel #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No
Associated Permit #:
APPLICANT: (hi 1<t
Phone: �gS 7-7(-06V ax:
Address (Street, City, State, Zip):
E-Mail Address: Avy
C I +1�jt M 114(,,(
PROPERTY OWNER:
4po
Phone:
Fax:
I
Address (Street, City, State, Zip):
E-Mail Address:
LENDING AGENCY:
Phone:
T Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* Paltz
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
*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 #/Exp. Date:
City Business License #/Exp. Date:
C)
PLUMBING MECHANICAL TANKI
I DEMOLITION
DETAIL THE SCOPE OF WORK:
f-Z-&
&S', OL,4
I declare under penalty ofperjury laws that the information I have provided on this jormlapplication is true, correct and complete,
and that I am the property owner or duly authorized agent of the propeny owner to submit a permit application to the City of
Edmonds.
Print Name: fix I f ) tmln '04 OwncrEl� Agent/Other 0 (specify):
Signature: t: Date:
FORMC LTuilding New Folder 2010\DONE & x-ferred to L-Building-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
I Drinking Fountain
Dishwasher
Clothes Washer
Rose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? YesE] Noo
Hydronic Heat in: Floor El wall El
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
MW I V1101 19M �
Equipment Type
�Ml I
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—Other:—
# BTUs: <100k— >100k—
Location(s)
Air Handler / VAV
(circle selected)
Gas #—Elec
#—Other:—
#—CFM: <10k— >10k—
Location(s)
AC / Compressor
Boiler / Heat Pump
Roof Top Unit
(circle selected)
Gas #—Elec
HP:
#—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:—
# Locatiou(s)
[Dryer Duct
rjm�� M
Appliance Type
0
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s):_
Furnace
BTUs: Location(s):-
Water Heater
Boiler
BTUs: Location(s):_
BTUs: Location(s):
Other:
Fireplace/Insert
BTUs: Location(s):-
BTUs: Location(s):-
Stove/Range/Oven
Dryer
BBQ
IOutdoor
I TOTAL OUTLETS
FORM C LABuilding New Folder 201 0\130NE & x-ferred to LBuilding-New drivc\Form C 2014.docx I Updated: 1/17/2014