20170906121238.pdfDEVELOPMENT 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 Qtreet, S City State, Zip):
Parcel #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? YesE] N o
APPLICANT: ��W\A,
Phone:
-7-7,S- -7
Fax:
Lk2_S_ ZLI
Address (Street, City, State, Zip): tv P__ W
E-Mail Address:
LXA "wrM10-ts 9? -z,-7
—F,
PROPERTYOWNER: -C-Y T5,�,
Phone:
Fax.
LA Zs- 7 17-
Address (Street, City, State, Zip): 9kk %Z-tk.,L
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* 15vL0A.-,, C_QU_V*
�
Phone:
Fax:
Address (Street, City, State, Zip): Nc6-(oQ A-C, 77 7\JeT 77
-7
E-Mail Address:
, �� � le") �
WA State License #/Ex Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
'SWLT�CT19302p_
C' Business License #/Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
I—
-
PERM I I AITIA'A I 10N FOR
TPLUMBING I MECHANICAL L I TANK
DEMOLITION I I
DETAIL THE SCOPE OF WORK: K&1k\04QJe— WAV-1C Sert� J;ibTy--% ly\R� J2 �3ne
-30' Ti6NA it VUNN
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I declare under penalty ofperjury laws that the information I have provided on thisformlapplication is true, correct and complete,
and that I am theproperty owner or duly authorized agent of theproperty owner to submit apermit application to the City of
Edmonds.
Print Name: )?.Jm"A �� �.�Nwv OwnerEl Agent/Other /(specify):
Date:
Signature:
FOP,M C L: \13U I LD IN G D IV I S ION F I LES\DONE & x- ferred to L-B u i I d i ng-New d rive\Form C 2014.d ocx Updated: 1/17/2014
PLUMBING
FIXTURL COUNT
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.)
Water Service Line
Tub/Shower
Drinking Fountain
Dishwasher
Clothes Washer
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes 0 No
Hydronic Heat in: Floor El wall El
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
to I r"113 Iml
Equipment Type
�� -
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—Other:—
#— BTUs: <100k— >100k—
Location(s)
AirHandler/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,-3-15,_15-30
#— BTUs: <100k,
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 #—Elee
#—Other:—
# Location(s)
Dryer Duct
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
FORMC L:\BUILDING DIVISION FILES\DONE& x-ferred tol,-Building-Newdrive\Forra C2014.doex Updated: 1/17/2014