20171005105746.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
1215 1h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
el -
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No RI
APPLICANT-
A/m
P�o p e:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
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WL4111LL (2_ohM so,-7-,
PROPERTY OWNER:
Phone:
Fax:
Address (9trect, City, State, Zip):
E-Mail Address:
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LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
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Phone:
Fax:
Address (Street, City, State, Zip):
'7
E-Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
City Business License #/Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING MECHANICAL TANKI
I DEMOLITION[
DETAIL THE SCOPE OF WORK: 44714=o�t
Ideclare under penalty 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.
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Print Name:f24-1& L-z_� Owne ' Agent/OtherEl (specify):
. ...............
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Signature;,, Date:
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FORMC LABuilding New Folder 201000NE & x-ferred to L-Building-New driveTonn C 2014.doex Updated: 1/17/2014
P[AJMBING
FIX]JAZE (-'OLJN'I'
I
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? YesE] NoE]_
Hydronic Heat in: FloorE] WallEj
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
L_
Other:
I
MECHANICAL
Equipment Type
Appliance/Equipment Information (new and relocated)
M
Total #
Furnace
Gas #—Elec
#_Other:—
# BTUs: <100k— >100k—
Location(s)
Air Handier / VAN
Gas #_Elec
#—Other:—
#—CFM: <10k— >10k—
Location(s)
(circle selected)
AC / Compressor
Boiler / Heat Pump
Gas #—Elec
#_Other:--
#_ BTUs:—<100k,
100k-500k, 500k-lMil
Roof Top Unit
HP:
-<3,-3-15,
15-30
Location(s)
(circle selected)
Hydronic Heating
Gas #_Elec
k--In-Floor
__�Wall Radiant— Boiler BTUs:_
Location
Exhaust Fans (single
Bath #
Kitchen # Laundry #
duct)
—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
BTUs: Location(s):
Boiler
BTUs: Location(s):
Other:
BTUs: Location(s):
Fireplace/Insert
BTUs: Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
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FORM C L:\Building New Folder 2010\130NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014