20170911120305.pdf, IN
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5'h 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):
loo 5- 57-A /tve-- S 30 2--
Parcel #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No E]
Associated Permit #:
APPLICANT
Phone:
Y-x 5- '? Y,/ / -5 6 7
Fax:
Address (Street/City, State, Zip):
E-Mail Address:
44 50f. C2 ef
PROPERTY OWNER.-_j
Phone:
Fax:
AddrAs (Street, City, State, Zip):
/ 0 S— 7 �/ X,-z- 1� -46-
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR-*
Phone:
Fax:
Address (Street, CitylState, 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:
I — I
N a NO I I WILI UN 0 MI I HUM
IPLUMBING M CHANICAL "TANK
DEMOLIT ION
DETAIL THE SCOPE OF WORK: j.:.2.d /I- I A,' eV,4,)j0 M, A., i a
r
40A b'/u,,t C 3- hy�_ k4dzf li(AZ le 's f e /`z e z ef &J—W 'L./ k42 Alty ejee
I declare under penalty ofperjury laws that the information I have provided on thisfornvapplication 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: kl' Owner RI�Agent/OtherEl (specify):
Signature: Date: �7
FORMC LABUILD ING DIV IS ION FI LES\DONE & x-ferred to L-B ui Iding-New dri ve\Form C 2014.docx Updated: 1/17/2014
PLUMBING
FIXTURE 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?Yesl:l Nofv)
L'0!Sj
Hydronic Heat in: Floor 0 wall El
Floor Drain/Floor Sink
Other:
Re
I— frigerator water supply (for water/ice dispenser)
Other:
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elcc
#—Other:—
#_ BTUs: <100k >100k—
Location(s)
Air Handier / VAV
(circle selected)
Gas #
Elee #
Other: # CFM: <10k >10k
Location(s
AC / Compressor
Boiler / Heat Pump
Roof Top Unit
(circle selected)
Gas #—Elcc
HP:
#—Other:—
<3,_3-15,_15-30
BTUs:—<100k,
Location(s)
_100k-500k, 500k4MiI
Hydronic Heating
Gas #—Elcc
#—In-Floor
—Wall Radiant— Boiler BTUs:
Location
Exhaust Fans (single
duct)
Bath #—Kitchen
#—Laundry # _Other:
#_
Fireplace
Gas #—Elec
#—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
BT]Us: Location(s):
Boiler
BTU[s: Location(s):
Other:
BTUs: Location(s):
Fireplace/Insert
BTU[s: Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORMC L:\BUILDFNG DIVISION FILES\DONE &x-terred toL-Building-NewdriveTorm C2014.docx Updated: 1/17/2014