20170913114318.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5"' Avenue N, Edmonds, WA 98020
Phone 425.771.0220 2 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & ME�HAATICAL CHECKLISTFOR SUBWTTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
8716 Madrona Lane, Edmonds, WA 98026
00504700201400
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? YesD No 7
Associated Permit #:
APPLICANT:
Filco Company Inc.
Phone:
206-547-8347
W-548-9352
Address (Street, City, State, Zip):
PO Box 31228 Seattle, Washington 98103
E-Mail Address:
info@filcoenviro.com
PROPERTY OWNER:
Rob Schmaus
Phone:
206-910-8957
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
8716 Madrona Lane, Edmonds, WA 98026
schmausr@gmail.com
LENDING AGENCY:
Phone:
Fax:
Address (Street� City, State, Zip):
E-Mail Address:
CONTRACTOR:*
Phone:
Fak:
Filco Company Inc.
206-547-8347
106-548-9352
Address (Street, City, State, Zip):
PO Box 31228, Seattle, Washington 98103
E-Mail Addkess:
info@filcoenviro.com
*Contractor must have a valid City ofEdmonds business license
prior to doing work
WA State License #/Exp. Date:
, FILCOCIO80RU 10/10/2015
City Business License #/I- D t
INR-0241 Ll ff'/31�2017
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK. Pump, rinse and fill in place with foam, one 300 gallon
residential heating oil tank. Cut vent and fill pipe below grade.
I declare underpenalty ofperjury laws that the information Ihaveprovided on thisfornVapplication is true, correct and complete,
and thatl am theproperty owner or duly authorized agent of theproperty owner to submit apermit application to the City of
Edmonds.
PrintName: —t';m
OwnerE] Agent/Other FZ] (specify)- Contractor
Signature:
Date: .,9r/ 7
FORMC MTVIVP X, —f—d f� I r' ')nl A 1— 1,- 1— 1. 1 1. 1 1".. .
M.EDICAIIL,GAS, AIR, VACUUM
Type of Gas/Air/Vacuum System (new and relocated)
Totalft
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 PlaceFv—/]
Fill Material foam
Fill in Place
Fill Material
Removal
Remova
Number of Gallons:
Number of Gallons: 300 gallon
Critical Areas Determination: Study RequiredE] Conditional Waiver El Waiver
L_j
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 El Conditional WaiverEl Waiver 0
PSCAA Case No.
AHERA Survey done? (required)
Additional comments:
'Pn1?U (' T -X131A:-- IT--.. 1_1_�Al At-^- 0_ -__� I ... IA-'-- IT—. - .