20171009165128.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
1215'h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLISTFOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
1115- 4LA-L,& q86U
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes D No
Associated Permit
APPLICANT:
F&Wk r
Phone-
4jX1
Fax:
Address (Street, City. e,
Zl*l)):,,
E-Mail Address:
UL�
P,
14 ryd, WA
W
PROPERTY OWNERVyV(4,0!
4M
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip).
E-Mail Address:
CONTRACTOR:*
Phone:
Fax:
Address (Street, City, Stat6, Zip):
E-Mail Address:
WA §fate LicenseWEAp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing ivork
ness�icense II/Exi). Qate:
F75�� -):3 't PI
in the City. Contact the City Clerk's Office at 425.775.2525
N a go I I MIN ME LWAV I M1,
TPLUMBING MECHANICAL TANKI
I DEMOLITION
DETAIL THE SCOPE OF WORK:
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.
)Agent/OtherEJ
Print Name: _(::0Zn�er (specify):
Signature: Date:
FORMC L:\BUILDING DIVISION FILES\DONE & x-ferred to L-Building-New driveTorm C 2014.docx Updated: 1/17/2014
M PLUMBING
Fixture Type (new and relocated)
Total #
FIXTURE COUNT
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
I Drinking Fountain
Dishwasher
Clothes Washer
Hose Bib
Backflow Prevention Device (�.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes E] No[:]
Hydronic Heat in: Floor El wall El —
Floor Drain/Floor Sink
Other: Pat l 11
I Refrigerator water supply (for water/ice dispenser)
Other:
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—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 #
HP:
Elec #—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)
D�;cr 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\FormC2014.docx Updated: 1/17/2014