Application.pdf0 ED�1r)
City of Edmonds
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 4 Fax 425.771.0221
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADaDRESS (Street, Sui a #, City State,Zip)- 1
V
Parcel #:
4 � �
f J f�o2 Y
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No E
APPLICANT:
Phone:Fax:
a nG �7i /9Q
Address Street, City, State, ip :
E -Mail Address:
e--YYI , f
PRVER' "'�" ,O VER:
Phone:
Fax:
A ess ( treet, City, State, Zip):
E -Mail Address:
LENDING AGENCY:
Phone: _T 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 I I TANK
DEMOLITION
DETAIL THE SCOPE OF WORK:
Y x
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 properly owner o .de authorized agent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: Owner ❑ Agent/Other ❑ (specify):
Signature: a "� �, Date:
0
FORM C LABuilding New Folder 2010\130NE & x-ferred to L -Building -New driveTorm C 2014.doex Updated: 1/17/2014
PLLJMBING
Fixture Type (new and relocated)
Total #
Fl XTU RE CO U NT
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
_.....---_
Pressure Reduction Valve/Pressure Regulator
. . ........... __.--_--_
#_Other:
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
.......---
Location(s) _ .........
Water Service Line
(circle selected)
.._....
Tub/Shower
BTUs: Location(s): ...
Drinking Fountain
Other. ._.(s)
Dishwasher
AC / Compressor /
Clothes Washer
BTUs:,,,- Location(s): _ __�.
..........
Hose Bib
Stove/Range/Oven
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Boiler / Heat Pump /
Water Heater Tankless? Yes ❑ No ❑
#_Other:............................................................
Hydronic Heat in: Floor ❑ Wall ❑
100k -500k, 500k-lMil
Floor Drain/Floor Sink
Roof Top Unit
Other:
TOTAL OUTLETS
Refrigerator water supply (for water/ice dispenser)
Other:
(circle selected)
Equipment Type
Furnace
Gas #
Elec #_Other:
Appliance/Equipment Information (new and relocated)
# BTUs: <100k_ >100k Location(s) ........ ITIT,_mm
Total #
Air Handler / VAV
Gas #_Elec
#_Other:
#_CFM: <10k_ >10k_
Location(s) _ .........
BTUs: Location(s,):
(circle selected)
Boiler
BTUs: Location(s): ...
_
Other. ._.(s)
BTUs: M.... m. ......_ Locatiatn �,:
AC / Compressor /
Fireplace/Insert
BTUs:,,,- Location(s): _ __�.
Stove/Range/Oven
Boiler / Heat Pump /
Gas #_Elec
#_Other:............................................................
# BTUs:.,,,,.._<100k,
100k -500k, 500k-lMil
Roof Top Unit
HP:............................_<3,
TOTAL OUTLETS
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 # _Other:
duct)
Fireplace
Gas #,—Elec
_Other:.,,,,,_....... # Locatioa(s)
Dryer Duct
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. ._.(s)
BTUs: M.... m. ......_ Locatiatn �,:
Fireplace/Insert
BTUs:,,,- Location(s): _ __�.
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\130NE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014