Application.pdfel ^
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
°s t4tt 121 5"' Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A 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 #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No
APPLICANT: Phone: Fax:
-1&101 a 1M tw it 0
Address(Street i1 State, p- C� �dress',
po-7� n' � µ
C 6 f MC1; I tom
PROPERTY OWNER: Fax:
Address (Street, City„ State, Zii)): E -Mail Address;
dao q SLU
LENDING AGENCY., Phone: Fax:
Address (Street, City, State, Zip)„ E -Mail Address:
CONTRACTOR:* I awry p /� Phone: Fax:
.s K 4� p tr".✓ C rV 1 F;.� 51+ V4.f 1
Address (Street, City, State, Zip): E -Mail Address:
�A Y►� c s k �� ✓ -
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work _ �P R 114 L-
in the City. Contact the City Clerk's Office at 425.775.2525 Cit 11ai'iness License #/F -p. Dater
L5
PERMITAPPLICATION FOR:
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK:. .....
Itt S
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.
Print Name:'-.. � k- G �n w.....�.�_ Owner ❑ Agent/Other (specify): .,.,...____�. _.....
g ..._
Si nature: ._... _ �._. �_.._..� _...... _ Date ._ll-!.�..�!....
FORM C L:\Build ng New Folder 2010\DONE & x4ei7ed to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Forin C 2014.docx Updated: 1/17/2014