20171011115856.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
1215 1h Avenue N, Edmonds, WA 98020
t *IS,) Phone 425.771.0220 0 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 #:
ro
00415LvD0600361
61
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes 0 N.X
Associated Permit #:
APPLICANT;T6t n -Da I las
Phone: Z_45)LP
13 -6)ZA �
Fax. 2-o (.o
I �3 jp 1 -0q12-
Address jp)-
I _�feet, City,-�Sta,e
_7 !2f�Z [._4)
tiff, i46r C:r-, LF10 IqF/5.5
E-Mail Address:+
_jLn le-6 lot &t
f-CA-11 LS d
PROPERTY OWNER: 41 .-
Lf,[Ah NeAson
Phone: Z.01.�5
Cl i 0)
Fax:
Address (Street, Y, State. Zip): I'd
3W rnt 0- 5
E-Mail Address:
L-j2(!,o3e7&aoj�uM
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
V "Daw
Phone:
Fax:
Address (Street Rit , State Zip)-
E-Mail Address:
WA State License #/Exp ate:
t,3 * W i F
*Contractor must have a valid City of Edmonds business license prior to doing work
City Business License #/Fxp. Date:
E
in the City. Contact the City Clerk's Office at 425.775.2525
11�03
PLUMBING MECHANICAL TANK M
DEMOLITION
DETAIL THE SCOPE OF WORK: 7P
vi a hd lix rrd ri*� 500
ciatt&�
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Vylifi
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Ideclare underpenalty ofperjury laws thatthe information I have provided on this formlapplication is true, correct and complete,
andthatlarn theproperty owner or duly authorized agent of theproperty ownerto submit a permit application to the City of
Edmonds.
Print Name: 0 ri D/I I 0,S C7 141 L4wnerEl Agent/Other 0 (specify): r
Signature: --- Date: _10 A-
-7
FORMC LABuilding New Folder 201000NE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/1712014
PLUMBINC
Fixture Type (new and relocated)
Total #
FIXTLRE COUNT
Fixture Type (new and relocated)
Water Closet (Toilet)
Pressure Reduction Valve/Pressure Regulator
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Water Service Line
Tub/Shower
Drinking Fountai
nr
Dishwasher
Clothe&WA-s-her
Hose Bib
JAHydronic
ackilow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes No 0
Heat in: Floor WaHE]
Other:
Floor Drain/Floor Sink
Refrigerator water supply (ro��,- �ice dispenser)
Other:
�M I ME RIM
M
Equipment Type
go
AppliancelEquipment Information (new and relocated)
Total #
Furnace
Gas #
Elee #—Other:—
# BTUs. <100k_ >100k_
Location(s)
Air Handier / VAV
(circle selected)
Gas #
Elec
Other:
# CFM: <10k— >101, —�—ocafl
Location(s)—
A C / Compressor
Boiler / Heat Pump
Roof Top Unit
(circle selected)
Gas #
HP:
Elec #
<3, __-3-15,
Other:—�
— S:—<100k,
#-- ___—jOOk-500k,
�15�-30,,cation(s)
—500k-lMil
Hydronic Heating
Gas #—Elec
#—In-Fly-f!��Wall
Radiant_ Boiler BTUs:
Location —
Exhaust Fans (single
duct)
Bath #—!�I,aundry
# ---Other:
#
Fireplace
Gas #,,'191ec
#---Other--
#— Location(s)
Dryer Duct
Appliance Type
Appliance/Equipment 12L6�n (new and relocated)
Total #
AC Unit
BTUs: Locatio :_ —
Furnace
BTUs: cation(s):
Water Heate
BTUs: Location(s):
Boiler
BTUs., Location(s):
Other:
BT Location(s):
Fireplace/Insert
4613s: Location(s):
-Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 20100ONE & x-ferred to L-Building-New driveTorm C 2014.docx Updated: 1/1712014
Type of Gas/Air/Vacuum System (new and relocated)
Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical - Surgical Vacuum
Other:
I TOTAL OUTLETS
TANK #1
WN
TANK #2
Method of Abandonminq
Method of Abandonment
FRI in Place Fill Material-M VL 1,)
V V
rL�
Fill in Place FM
Material
Removal 'Ej
�J
Removal E]
Number of Gallons: cSdo r
Number of Gallons:
Critical Areas Determination: Study Required
Conditional Waiver Waiver
Type of structure to be demolished (e.g. house, shed, garage, etc.):
Floor area of structure to be demolished: sq. ft.
I Critical Areas Determination: Study Required Li -Pmdrional Waiver LJ Waiver Lj I
I PSCAA Case No. I AHERA Survey done? (required) El I
Additional comments:
FORM C L:\Building New Folder 2010DONE & x-ferred to L-Building-New drive\Forrn C 2014.doex Updated: 111712014
FILL
61D LOCATE SOIL SAMPLES REMOVAL
R ! SEAF
ECO SEARCH COMPLETED
NAME t VIL soyl DATE
SITE ADDRESS I!M
-4.1 r tit ( 4
PHONE
EMAIL
ANIMALS YIN
TANK SIZE so ti
WATER@N POWER-4
DIAMETER -tA'l TOTAL
c
LAY OF TANK FILL GRADE LENGTH --k —GROUND COVER Vor
CONTENTS OIL'f % � . WATER — OTHER —TOTAL
WHAT TRUCKS CAN WE BRING TO THIS SITE?
L-,A
OFFICE NOTES: -lany,
FIELD NOTES:
I VACANTY/�
FILL PIPE: 35
f� I L
JOB COMPLETED BY: qDAT
Site info taken by: ------ (-�Ynjo &Y- Deadlineimyl