20171023104058.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
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PERMIT APPLICATION
121 5'h Avenue N, Edmonds, WA 98020
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Phone 425.771.0220 Ik Fax 425.771.0221
City of Edmonds
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PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No R
APPLICANT:
Phone: Fax:
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Address Street City, 'Mate, Zip):
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E-Mail Address:
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PROPERTY OWNER:
Phone: Fax:
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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, State, Zip);
E-Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
'PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK y
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I declare under penalty of perjury laws that the information I have provided on this form/application 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 Ya TIr I I_ X," Owner ❑ Agent/Other ❑ (specify).
Signature:° Date:
FORM C L:\BUILDING DIVISION FILES\DONE & x-ferred to L-Building-New drive\Form C 2014,doex Updated: 1/17/2014
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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)
_.... wm.... ............. � ........._..............
Water Heater Tankless? Yes No
y �.�w �_ .....
H dronic Heat in: Floor Wall
Floor Drain/Floor Sink
Other:
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 Handler / VAV
Gas #
Elec #
Other:
# CFM: <10k >10k:
Location(s)
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Gas #,Elec
#Other:-
------ _
# BTUs: <100k,
100k-500k, 500k-1Mil
Roof Top Unit
HP:
<3,
3-15, 15-30
Location(s)
(circle selected)
Hydronic Heating
Gas #—Elec
#--In-Floor
_Wall Radiant— Boiler BTUs:
Location , .......
Exhaust Fans (single
Bath #
Kitchen # Laundry #
#
duct)
_Other: �_ITITITITITIT
Fireplace
Gas #
Elec #_Other:
.,.
# Location(s)
Dryer Duct
Appliance Type
al 1111 all
Appliance/Equipment Information (new and relocated)
T11 ota11 l #
AC Unit
BTUs: �mm _,_,.
Location(s):...,
Furnace
BTUs Location(s):
. . .....
__- ...... ........
Water Heater
BTUs: Location(s)„
�.
Boiler
BTUs; Location(s):
Other, _
BTUs: v_.__ .... Location(s): __
Fireplace/Insert
BTUs:......._ _ Location(s):, .............._
Stove/Range/Oven
............
_ .._...__ .......
Dryer
Outdoor BBQ
TOTAL OUTLETS
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