BLD20160536.pdfCity of Edmonds
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 58'Avenue N, Edmonds, WA 98020
Phone 425.771.0220 2 Fax 425.771.0221
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
8028 212TH ST SW EDMONDS 98026 0109590001700
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT: MM COMFORT SYSTEMS Phone: Fax:
[42-5-88-1-792011
Address (Street, City, State, Zip): E -Mail Address:
18103 NE 68TH ST, C-200 REDMOND, WA 98052 JWELLS@MMCOMFORTSYSTEMS.COM
PROPERTY OWNER: Phone: Fax:
MARK JACOBS 206-851-2771
Address (Street, City, State, Zip): E -Mail Address:
8028 212TH ST SW EDMONDS 98026
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* MM COMFORT SYSTEMS Phone: Fax:
425-881-7920
Address (Street, City, State, Zip): E -Mail Address:
18103 NE 68TH ST, C-200 REDMOND 98052 JWELLS@MMCOMFORTSYSTEMS.COM
WA Slate License #/Exp. Date: 09/24/2017
*Contractor must have a valid City of Edmonds business license prior to doing work MMf �OMCS85564
in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
NR -022651 12/31/16
PLUMBING ME11AN'1CA1 =EEMOLITION
DETAIL THE SCOPE OF WORK: --. .,...... ,,,,,,,,._..... .........._ .— _ ..��.....W.
_.......... _...w.... ......,,..,_A,.e,�......__.. __ .. �.
I
INSTALL NEW A/C UNIT
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: AMANDA EIS"IT Owner ❑ Agent/Other ❑ (specify):... .�
Signature:._– _----------
4121116
.... �_. Date: _... __._.
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New driveTorm C 2014.doex Updated: 1/17/2014
Fixture Type (new and relocated) Total # Fixture Type (new and relocated)
Total #
Water Closet (Toilet) Pressure Reduction Valve/Pressure Regulator
n
Appliance/Equipment Information (new and relocated) Total #
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.) Water Service Line
Gas #Elec
Tub/Shower Drinking Fountain
# BTUs: <100k >100k
_
Dishwasher _ Clothes Washer
Air Handler / VAV
Hose Bib Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Elec ft—Other
.._..__....-- _._.v....... .............. ...-_-... .
Water Heater Tankless? Yes ❑ No ❑ Hydronic Heat in: Floor ❑ Wall ❑
............. .-._
Floor Drain/Floor Sink Other:
Other: .
_..._
Refrigerator water supply (for water/ice dispenser) Other:
......
Equipment Type
Appliance/Equipment Information (new and relocated) Total #
Appliance/Equipment Information (new and relocated) Total #
Furnace
Gas #Elec
#_Other:
# BTUs: <100k >100k
Location(s)
Air Handler / VAV
Gas #
Elec ft—Other
. # CFM• <10k >10k
Location(s)
(circle selected)
Other: .
BTUs:
......
Fireplace/Insert
A(. € ."otttpressor /
... ............
_-. Locations):..
Stove/Range/Oven
rdIer / I lead pump /
Gas k
Elec #e„e
t Itlker: # BTUs: <100k,
100k -500k, 500k-lMil
Roof Top Unit
HP:
<3,
3-15, 15-30 Location(s) ®m
(circle selected)
Hydronic Heating
Gas #
Elec #
In -Floor _Wall Radiant--- Boiler BTUs:
I ^ca*i: w
Exhaust Fans (single
Bath #
Kitchen # Laundry # Other:
duct)
Fireplace
Gas #Elec
#
Other: .. .........
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated) Total #
AC Unit
BTUs:
Location(s):.,.. ... _............... ___— .... . .....
Furnace
BTUs: ,Nm
m Location(s): _ __ ._._...... .
Water Heater
BTUs:
Boiler
BTUs:...
.. _._.., f oeation(s):.
Other: .
BTUs:
1 ocation(s) .. a. ..__._ u.._
-- ..,,,,,....... _
Fireplace/Insert
. _.
BTUs:
... ............
_-. Locations):..
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.docx Updated: 1/17/2014
Type of Gas/AirNacuum System (new and relocated) Total#
Oxygen
v ........
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical — Surgical Vacuum
Other:
TOTAL OUTLETS
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
Fill in Place ❑ Fill Material Fill in Place ❑ Fill Material_
Removal ❑ Removal ❑
Number of Gallons _Number of Gallons:
Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver E] W
Type of structure to be demolished (e.g. house, shed, garage, etc.): , . ,__9„�,, _,,......_ � �.. ..�.......,
Floor area of structure to be demolished: sq. ft.
_.......... ._ _ ....
Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑
PSCAA Case No.. AHERA Survey done? (required) ❑
Additional comments: _
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New driveTorm C 2014.doex Updated: 1/17/2014
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