20180108122520.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 CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
7 6 19 -1 -7 ft�- 5+- <- kJ
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No
Associated Permit #:
APPLICANT- -
�j e
y1j, _.S.
Aoqe:
6V(,f 71V-17VI
Fax:
Address (Street, City, State, Zip):
-7, 't�- W
E-Mail Address:
2 6 1 q - 1 q .5
1
PROPERT.Y OWNtR-
�Er 62, �.
Phone:
Fax:
I
,�: )(->- V1 V1 I Y—K
Address (Street, City, State,
E-Mail Address:
q,
26 14-17
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACT01
t7-1 .- �1 -T-4oxibit4l;
P one
!7jE M
*E-Mail
Fax:
,4,�dress L�_treet, City, S te Zij- '
fer:)
_M i Address:
WA State License 0/ExI 1) te:
7 Lt, s-
*Contractor must have a valid City ofEdmonds business license prior to doing work
( 4 1
City Business License #/Exp. Date:
APDJ����_
in the City. Contact the City Clerk's Office at 425.775.2525
ITIM I APPIACA I [ON FOR
TPLUMBING I I MECHANICAL TANK
DEMOLITION I I
DETAIL THE SCOPE OF WORK: ce I yl 1&.r r
11X4 hA d b "A 1,_\rjtWK
b4v e. a e a gr ve i
�_j
I declare under penalty ofperjury laws that the information I have provided on thisform/application is true, correct and complete,
and that I am theproperty owner or duly authorized agent of theproperty owner to submit a permit application to the City of
Edmonds.
Nan rot Owner Agent/OtherEl (specify):
[Print
SignatureM: Date:
FORMC LABUILDING DIVISION FILES\DONE & x-ferred to L-Building-NewdriveTorm C 2014.doex Updated: 1/17/2014
PLUMBING
FIXTURE COUNT
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 (�.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes 0 NoE]
Hydronic Heat in: Floor El wall El
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
MECHANICAL
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #—Elec
#—Other:—
#-- BTUs: <100k— >100k—
Location(s)
Air Handier / VAV
Gas #
Elce #
Other: # CFM: <10k >10k
Location(s)
(circle selected)
AC / Compressor
Boiler / Heat Pump
Gas #
Flee #—Other
BTUs: <100k,
_100k-500k, 500k-IMil
Roof Top Unit
HP:
Location(s)
(circle selected)
-<3,-3-15,_15-30
Hydronic Heating
Gas #—Elec
#—In-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):
Other:
BTUs: Location(s):
Fireplace/Insert
BTUs: Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORMC L:\BUILDfNG DIVISION FILES\DONE & x-ferred to L-Building-NewdriveTorm C 2014.doex Updated: 1/17/2014