BLD20160670.pdf3y DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
I,S>t 121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220'k Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PRO ECT ADDRIrSS (Street, Suite #, City Shite, Zip): Parcel #:
23q2,0 �VVW� W2,6
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT:� � � Phone: Fax:
Address (StreeOCity, St e, 2ip): � A7)65,1ILLE- U# 1,4,2-71 E -Mail Address:
JAL70
PROPERTY OWNER: Phone: Fax:
AddressStreet„ City, State Zip): MD2 / E -Mail Address:
,,2q7 T S Wj
LENDING AG NCY: Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
Y
..CONTRACTOR:*6 � � nom./ � O Phone:80� Z Fax;,
Address (Street, City, State, Zip): (��f 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 DEMOLITION
c ..c i...� / �..........
DETAIL THE SCOPE OF WORK, __..
CC (, �yz r C/'7'j TOO' I 7-S' .
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 � � tOwner AgentJOther ❑ (specify): , ,,,
Signature: —�x ... 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 Type (new and relocated)
Total #
FIXTURE COUNT
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
Furnace
Pressure Reduction Valve/Pressure Regulator
w Elec #,.._.....-.Other:...._
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Location(s)
Water Service Line
Air Handler / VAV
Tub/Shower
#,Other:
Drinking Fountain
Location(s)
Dishwasher
(circle selected)
Clothes Washer
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
kl Compressor /
- .. ..........�
Water Heater Tankless? Yes ❑ No ❑
Hydronic Heat in: Floor ❑ Wall ❑
100'k SOOk-1Mi1
Floor Drain/Floor Sink
33 t er / Heat Pump /
Other:
Elec #„
Refrigerator water supply (for water/ice dispenser)
-500k, _LL
Other:
Roof Top Unit
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #
w Elec #,.._.....-.Other:...._
. #� BTUs: <100k >100k
Location(s)
Air Handler / VAV
Gas #_Elec
#,Other:
#_ <lOkmIT >10k—
Location(s)
(circle selected)
,_ww—www___ .. . _ ,,,,WCFM: _
kl Compressor /
# i
100'k SOOk-1Mi1
33 t er / Heat Pump /
Gas #
Elec #„
Other: ..�__. . 1"iTs: 1-mm<100k,
-500k, _LL
Roof Top Unit
HP:
<3 ....................
3-15 .................. .15-30 Location(s)
f
(circle selected)
Hydronic Heating
Gas # ..... _
..... Elec #
In -Floor _Wall Radiant _._._.__ Boiler BTUs:_.—
Location*,,
Exhaust Fans (single
Bath #_Kitchen
#_Laundry #
# .......
duct)
_fltltta
Fireplace
Gas #_Elec#_Other:
# Location(s)_µµmm---...._......�_„,,,
_-
Dryer Duct
Appliance Type Appliance/Equipment Information (new and relocated) Total #
AC Unit BTUs .... v ....... Location(s):�F- .1�_� �_..._. �� .%alai
Furnace BTUs: „ Location(s):
Water Heater BTUs: ......... _....� Location(s):._..,n_ WW......_..
Boiler BTUs:........ 9 Location(s)_.....................................� _.... ._...-.
....................._...........
Other: _..ww�.. BTUs: ......................Location(s)_.........---...._ ._..— ..........._._
Fireplace/Insert BTUs: ......
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
R0 bb0 1030/X.�
FORM C L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014