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FIELD NOTES:
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FORMC L:\Buildi,g New Folder 2010\DONE & x-ferred to L Building -New driveToirn C 2014.doex Updated: 1/17/2014
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
1215 1h Avenue N, Edmonds, WA 98020
S t" Phone 425.771-0220 4 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 #:
( �j )
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT,� Phone: � c
' I . �y, �
Address (Street, City, Statex ip ., , r'7 ;1, E -Mail Address. -
/,,..
Address (Street, City, State, Zi,t
Lin -z-1; :ii, -
LENDING AGENCY:
Address (Slret!Cif"tate, Zip):
CONTRACTOR
Address (Street, City, State, Zip):
*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
PLUMBING MECHANICAL I TANK
DETAIL THE SCOPE OF WORK: u-_...$ 'y
...
a 4",
Phone: 1
E -Mail Address:
Phone: i Fax:
E -Mail Address:
Phone: Fax:
E -Mail Address:
WA State License #/Exp. Date:
City Business License #/Exp. Date:
DEMOLITION
FM
Im
0
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:. �" _ W OwnerEj Agcntl(Itk (specify)
).,
Signature: " .-Date:.
.6
FORM C LABuilding New Folder 2010XDONE & x-ferred to L Building -New driveWl=oogi C 2014_docx Updated: 1/17/2014
Fixture Type (new and relocated)
Water Closet (Toilet)
Sink (latchcn laundry, lavatory, bar, eye wash, etc,)
.. ..._.. - _ .. ...
Tub/Shower
............mm
Dishwasher
........................... __
Hose Bib
Water Heater Tankless? lac' No ❑
Floor Drain/Floor Sink
Refrigerator waters ply (for water/ice dispenser)
Equipment' "ylW
Furnace
Air Handler / VAV
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Roof Top Unit
(circle selected)
Hydronic Heating
Exhaust Fans (single
duct)
Fireplace
. .............
Dryer Duct
Appliance Type
AC Unit
........ .......
Fu_.....
rnace
Water Heater
Boiler
Other:__. ............._
Fireplace/Insert
Stove/Range/Oven
Dryer
Outdoor BBQ
Total # Ixturc Type (new and relocated)
essu,rc Reduction Valve/Pressure Regulator
Service Line
�. Water Ser _ ...._.... _ �..�„„�
Drinking Fountain
..... ........ ..........
Clothes Washer
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Hydronic Heat in: Floor ❑ Wall ❑
Other: _ m...
Other: ��.-.� .. ....
Total #
Appliance/Equipment ltlfor�a A ion (new and relocated) Total #
Gas # Elec k Other: # ]s: <100k >100k_ Location(s)
Gas ala="M:<10k_>10k
Gas k Elec #_t"."tther.,_-..,_,,,, #_BTUs: <100k, 100k -500k, $00k-IMil
HP:34 15,3
15-m'4'0 Locations)
Gas k E/fL-floor _Wall RadiantBoiler BTUs:Location
Bath #— Laundry # ..... Other;_ Gas # P_ther: #
Appliance/Equipment
BTUs: Location(s):
BTUs: _ _ Lzti
BTUs: l
BTUs _ Location(s):
BTUs ...._ ..._ _...
BTUs: .............. Location(s)-
AL OUTLETS
and relocated)
Total #
FORM C LABuilding New Folder 2010\130NE & x-ferred to LrBuilding-New drive\Form C 2014.docx Updated_ 1/17/2014
5