20171009124933.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5'h 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):
Ct 00 / )_0 V 5 1.,
Parcel #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? YesE] NoE]
Associated Permit #:
—I
APPLICANT: 4le-k
Phone: 2- 7-1?
Fax:
Address (Street, Ci ty , tate, Zip):
U5 5 4r,4' 3� � e,- 44 2 9) 92f
E-Mail Address:
PROPERTY OWNER:
F_/-C_j
Phone:
VS-7.2�-79S'-1
Fax:
I
Address (Street, City, State, Zip):
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* a
I 1'i6al- �
Phone:
2C16)M- �) 70
Fax:
Address (Street, City, State, Zip):
ILI 4 L(I"' 6 5e, L 4, d I VS12
E-Mail Address:
6 � et ,� &'r- P -,- *d, . c. M
*Contractor must have a valid City ofEdmonds business license prior to doing work
in the City. Contact the City Clerk's Office at 425.775.2525
WA $tate It"lcense #/Exp. Date:
Akj�6011_ qt/, � if Z _S /q
City Business License #/Exp. Date:
ITIM I AITIAWI ION [OR
PLUMBING
DETAIL THE SCOPE OF WORK: Wo,(.e. �J e,, sa"e_ L .-.e. o t— 7e,,
I declare under penalty ofperjury laws that the information I have provided on thisfornMapplication is true, correct and complete,
and that I am the property owner or duly authorized agent ofthe property owner to submit a permit application to the City of
Edmonds.
Print Name: A& Ac OwnerEl Agent/Other (s p e C i ty): An
Signature: Date: Ple,'11 7
FORMC L:\BUILDING DIVISION FILES\DONE&x-ferredtoL-Buildiilg-Newdrive\Form C2014.docx Updated: 1/17/2014
PLUMBING
FIXTURE COUNT
I
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
N
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 (cg. 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:
ME('IIANICAL
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—Other:—
# BTUs: <100k— >100k.—
Location(s)
AirHandier/VAV
Gas #
Elec #
Other:
# CFM: <10k >10k
Location(s)
(circle selected)
AC / Compressor
Boiler / Heat Pump
Gas #—Elec
#—Other:--
#_ BTtJs:—<100k,
_100k-500k, 500k-lMil
Roof Top Unit
HP:
<3,_3-15,_15-30
Location(s)
(circle selected)
Hydronic Heating
Gas #—Elec
#_[n-Floor
—Wall Radiant— Boiler BTUs:
Location
Exhaust Fans (single
Bath #
Kitchen # Laundry #
duct)
_Other:
Fireplace
Gas #—Elec
#—Other:—#—
Location(s)
Dryer Duct
I
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):
BTUs: Location(s):
Other:
Fireplace/insert
BTUs: Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORMIC L:\BUILDING DIVISION FILES\DONE&x-ferredtoL-Building-Newdrive\Forin C2014.doex Updated: 1/17/2014