20170828103054.pdf9-4
Uh 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):
-7r7 �,v go,
arcel #:
TO acw_ At4
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No
APPLICANT.
;)Alje�Ll W/1_/_ 1,4/k -<
Phone:
Fax:
I
Address (Street, City' State Z*V:
"22_� �2.
E-Mail Address:
PROPERTY OWNER:
Phone:
Fax�
kj 4W &q LA-) t C (4,1&-
1
Address (Street, City,4�ffzip): Cl
-? Ili
E-Mail Address:
(I -.
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*,
aol'� la"IL
Phone:
Fax.206 -
LMO -1-7 9
,Addre�a (Street, City, State, Zip)*
PD ;� _7 _7_73 Siqffle WA 11177
E-Mail Addrfss:
T) 1 h
I, ex 1115 'q',l ko 6 6D 1-7
State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
I kil't 4" ql)G L�m 0/v 0 is,
in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
�N RM I J =111JUMMAN I MM Mt�
PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK: F� ft ion 14 (,p Ii/ -(D /0�
'70 Aedlak, he4ki-T ed OST,
I declare underpenalty 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.
if_ f9EWLAtt C_ T- Owner F1 Agent/OtheLZ A44*t__
Print Name: (specify):
Signature: Date: 264�/
I
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New driveTorin C 2014.doex Updated: 1/17/2014
MEDICAL GAS, AIR, VACUUM
Type of Gas/AirNacuum System (new and relocated)
Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical — Surgical Vacuum
Other:
TOTAL OUTLETS
TANK #1
TANK#2
Method of Abandonment
Method of Abandonment
Fill in Place Fill Material
Fill in Place
Fill Material
Removal z0-
Removal El
Number of Gallons:
Number of Gallons:
Critical Areas Determination:'Study Required E]
Conditional WaiverE]
Waiver E
Type of structure to be demolished (e.g. house, shed, garage, etc.):
Floor area of structure to be demolished: Sq. ft.
Critical Areas Determination: Study Required Conditional Waiver Waiver F1
PSCAA Case No.
AHERA Survey done? (required)
Additional comments:
FORM C LABuilding New Folder 201MDONE & x-ferred to L-Buildilig-New driveTorin C 2014.docx Updated: 1/17/2014