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DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
I•,It Uay�; 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 ft Fax 425.771.0221
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECTADDRESS (Street, Suite #, City State, Zip): 1. Parcel #:
n
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ NoX]
APPLICANT: P one: Fax:.
�<�L_t (,� -r, -+ A r"_ le 4 ij� Lf o 6d
Address (Stec t City, State, Zip : y r �� �� -Mail Address:
;> - - Pis u 7
PROPERTY OWNER: Phone: Fax:
Address (Street, City, State, Zip):: E -Mail Address,
LENDING AGENCY: Phone: Faxe
_U
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 TANK L1 DEMOLITION Ll
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.
Print Name: Owner Agent/Other ❑ (specify):
Signature: _ ..... ....... .. da.. Date ��.::.......
/
FORM C L:\Building New Folder 2010\130NE & x-ferred to L Building -New drive\Form C 2014.docx 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 j Clothes Washer
Hose Bib _ w___ . ....... Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
................
Water Heater Tankless? Yes ❑ No ❑ Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink[Other:
er:
Refrigerator water supply (for water/ice dispenser)
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #,,„Elec
#,—!l
thers.,–,....._,,,,,,,...,
# BTUs: <100k >100k_
Furnace
Air Handler / VAV
Gas #_Elec
#_Other:
-_-
Water Heater
#-----CFM: <lOk_ >lOk
Locations)
_ l.ottitt't(sM _.-.-. ... ..-..-. _ .._ .............._....
(circle selected)
Boiler
.......
BTUs:. .......
_ _.. Location(s,)-,__,, �_ .......
Other: ,. _
AC / Compressor /
BTUs:
Fireplace/Insert
BTUs:
Boiler / Heat Pump /
Gas #_Elec
#
Other: .______________-----
&tBTUs:—<100k -
100k -500k, .___________500k-1Mil
Roof Top Unit
HP: _...�<3.
. ,._.....
_.......... 3-15, ....... _15-30
Location(s) �.._..._....-.-.-..........�
�- a�...m_
(circle selected)
TOTAL OUTLETS
Hydronic Heating
Gas #
Elec #_In
-Floor Wall Radiant Boiler BTUs:
Location
Exhaust Fans (single
Bath #
# Laundry #
__('Itber:......._....................... �
._w .......---...... .....-
duct)
..........
.—Kitchen
........................
Fireplace
Gas #_ _........
Elec #_Other:..
................ _ .........
# ........ Location(s)_ ..... .......
_ ...... ....�m
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:..
.._� Location(s):_._............
Furnace
BTUs:y,w ,,,,,
_ mmmmm_m Location(s) ,,........ ,
-_-
Water Heater
BTUs: _
_ l.ottitt't(sM _.-.-. ... ..-..-. _ .._ .............._....
Boiler
.......
BTUs:. .......
_ _.. Location(s,)-,__,, �_ .......
Other: ,. _
_.
BTUs:
Fireplace/Insert
BTUs:
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-ferred to LrBuilding-New drive\Form C 2014.docx Updated: 1/17/2014
FORM C L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014,doex Updated: 1/17/2014
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
r PERMIT CHECKLIST
• 121 51h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft Fax 425.771.0221
City of Edmonds
PROJECT ADDRESS:
Plans shall
be of sufficient clarity to indicate the location, nature, and extent
of the work
proposed,
and conform to the provisions of
the adopted
International Codes and City Ordinances.
'
SUBMITTAL REQUIREMENTS
o
o x
w
,may. o
The number indicates the number of copies for submittal( if
applicable). Check marks indicate additional submittal
requirements that may apply to your project.
e
ificcation Form C
1
1
1 1
Site Plan
3
1
�.....
_........
Mechanical Plans
_...m_...
_ _ w -........
z
Manufacturer s Specifications/Cut Sheets
0
Elevation View for Roof Mounted 1 clttiPment
0
0
2 2
....
Structural Calculations
Plumbiai m Plans _
_......w
...,� 2 ....... .
Listed and Tested Fire St!2pp Assemblies
2
Washington State Contractors License
........ __
Contractor's City of Edmonds Business License
_.......__
_....
_WWW...
Critical Areas Determination or Checklist
... .... _
State Non -Residential Energy Code compliance forms
_... _.
2
• Handouts
and Standard Details may be found on the City's website
www'edalral
or can be obtained at City Hall
during
normal business hours.
• Plans/calculation/reports
prepared by state licensed architects or professional
engineers
must
be stamped and signed by the
design
professional.
FORM C LABuilding New Folder 201000NE & x-ferred to LAuilding-New drive\Form C 2014.docx Updated. 1/17/2014