application.pdfA,j
rw DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h 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 E] No
APPLICANT: SPhone: Fax:
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Address (Street, City, State, Zip : - ail�Ad ess: 1
00 Z. W erJ\A3e_ )cc oMa^ �OeN
PROPERTY OWN t:It: Pho e: Fax:
Address (Street, Cid,tate, Zip): E -Mail Address:
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LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* \ Phone: .Fax,
O C
Address (Street, City, State, Zip): E -Mail Address.
WA State License #/Exp. Date:
*Corara,ctor rniust ai)e a v lid City of Edmonds business license prior to doing work
in. the City. Contact the City Clerk's Q ice al 42.5e 775.2525 City Business License #/Exp. Date:
PLUMBING MECHANICAL TANK DEMOLITION
CACHr�e
DETAIL THE SCOPE OF WORK:. _�... ..,._ .. _ _. ._
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. �j
Print Name ✓ e Yy v e� 1 Owner A ent/Other (specify):.__—,,,-----
..........
_..�.�...... � � _w_� g � ...
Signature: _ Date:^..�-_—..........
_...
FORM C L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
PLUMBING
FIXTURE COUNT
MECHANICAL
Appliance/Equipment Information (new and relocated)
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
IAwation(s)n,,,..,,._
Pressure Reduction Valve/Pressure Regulator
Air Handler / VA V
Sink (kitchen laundry, lavatory, bar, eye wash, etc.)
#_Othe
Water Service Line
Location(s)__,,u.-„--r-�
Tub/Shower
(circle selected)
Drinking Fountain
Dishwasher
.. ,
Clothes Washer
AC / Compressor /
...,�, __..............
Hose Bib
M _...._.
Other:..�............�...........�...........-----.......
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
B 1 Us ....m.
_______.. . _
Nh
Water Heater Tankless? Yes ❑ No
.....W....
Hydronic Heat in: Floor ❑ Wall ❑
#.................
Floor Drain/Floor Sink
100k -500k, ............................
Other:
Roof Top Unit
Refrigerator water supply (for water/ice dispenser)
<3,
Other:
.
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #
Elec #_Other:.
# BTUs: <100k,-,,,,,- >100k_
IAwation(s)n,,,..,,._
.._.m_.._— ...........
Furnace
Air Handler / VA V
Gas #_Elec
#_Othe
:# <10k_ >10k,
Location(s)__,,u.-„--r-�
.......
(circle selected)
m. Location(s): ... _ __
,,.,..,CFM: mm,,,,
.. ,
BTUs:__
AC / Compressor /
M _...._.
Other:..�............�...........�...........-----.......
B 1 Us ....m.
-..._._ .
Location(s) ....... ____.
Boiler/ Heat Pump /
Gas #.................Elec
#.................
Other: .................. .................. .................... ' 9........................ BTUs:..............................<100k, ....................................
100k -500k, ............................
Roof Top Unit
HP:
<3,
3-15 Location(s),,, _
.
Dryer
(circle selected)
........15-30 ,,w,...
Outdoor BBQ
Hydronic Heating
Gas 4_____Elec
#
In -Floor'__,, ,,.,,_Wall Radiant_ Boiler BTUs:._
. Location_,
TOTAL OUTLETS
Exhaust Fans (single
Bath #........_...Kitchen
# # ... .---
duct)
.......................Laundry ww...,.Ot.Nlt.r.__Nww.,w
Fireplace
Gas #Elec
#_Other:
#
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: ___,_,
Location(ti)w,—��...� ._._. .,�______ ..............�
.._.m_.._— ...........
Furnace
......
BTUs:
Localion(s).._�_.. .........
.,,m
Water Heater
.......
,
BTUs:
m. Location(s): ... _ __
w ._ �.�.......
Boiler
BTUs:__
. , Location(s):............... �........
M _...._.
Other:..�............�...........�...........-----.......
B 1 Us ....m.
-..._._ .
Location(s) ....... ____.
Fireplace/Insert
BTUs --
.__w._. ..... _, Location(s)M......._..................__.. ---.w _. ......w..
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C', LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.doex Updated: 1/17/2014