BLD20160812-APP.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5"' Avenue N, Edmonds, WA 98020
Phone 425.771.0220 11 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 #:
LA r�
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes NoEl
APPLICANT: r11% I
Phone:
Address (Street, City, 2 State, Zip):
e au� E'duy)LD(A,
2
E -Mail Address:
Laet
PROPERTY OWNE•—go
—ne. Fax:
"t C,
Address (Street, City, State, Zip):
r s:
E -Mail Addil.
LENDING AGENCY:
Phone: Fax:
rAX--ess (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:* F
aDLPhone:
Fax: [a�C
Address (Street, City, State, Zip):
E -Mail Address:
fn
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 L-1 MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK: ick'aex,k ,5ti rm
'Van
I declare under penalty oj'peijury 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.
Q
PrintNarne: "/v C) as Owner Agent/Other
❑ (specify):
Signature: 6)NdggltDate:
FORM C LABuilding New Folder 201 O\DONE & x-ferred to L -Building -New driveTorm C 2014.docx Updated: 1/17/2014
«: P .UMB NC.I+IXTTTR>• COUNT
Fixture Type (new and relocated)
Water Closet (Toilet)
Total # Fixture Type (new and relocated) Total #
Pressure Reduction Valve/Pressure Regulator
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Water Service Line
Tub/Shower
Drinking Fountain
Dishwasher
Clothes Washer
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, Avu)
Water Heater Tankless? Yes ❑ No
Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
MVV14 A NIVA 1 .
Equipment Type
Appliance/Equipment Information (new and relocated) Total #
AC Unit
Appliance/Equipment
Information (new and relocated) Total #
Furnace
Gas #_Flee
#_—Other:—
Water heater
# BTUs: <100k_ >100k_
Location(s)
Air Handler / VAV
Gas #_Elec
#_Other:
Other:
#_CFM: <10k_ >10k_
Location(s)
(circle selected)
BTUs:
Location(s):
Stove/Range/Oven
AC / Compressor /
Outdoor BBQ
Boiler / Heat Pump /
Gas #_Elec
#_Other:
# BTUs: <100k,
100k -500k, 500k-1Mil
Roof Top Unit
HP:
<3,
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:
#_ Location(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:
BTUs:
Location(s):
Fireplace/Insert
BTUs:
Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLET'S
FORM C L:vBuilding New Folder 201MONE & x-ferred to L -Building -New drivevFonn C 2014.docx Updated: 1/17/2014
IV F.I)ICA 1, C Aq, AIR_ VACUUM
Type of Gas/Air/Vacuum System (new and relocated) Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical — Surgical Vacuum
Other:
TOTAL OUTLETS
TANK
TANK #1
Method of Abandonment
Floor area of structure to be demolished: sq. ft.
Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑
TANK #2
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 ❑
11 IIFAA01 .ITION
Type of structure to be demolished (e.g. house, shed, garage, etc.):
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 I- ABuilding New Folder 2010vDONE & x-ferred to L -Building -New drivevForm C 2014.docx Updated: 1/17/2014
v DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT CHECKLIST
121 5°i Avenue N, Edmonds, WA 98020
Fs t• 1 ��o Phone 425.771.0220 4 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.
Handouts and Standard Details may be found on the City's website www..edmondswa.gov 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 L:\Building New Folder 2010\DONE & x4erred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
d
o
-
SUBMITTAL REQUIREMENTS
R.
The number indicates the number of copies for submittal( if
70 �
C
V
applicable). Check marks indicate additional submittal
E W
:0
requirements that may apply to your project.
mm
Application Form C
1
l
I
1
Site Plan
3
_
1
Mechanical Plans
2
Manufacturer's S ecifications/Cut Sheets
0
0
2
2
Elevation View for Roof Mounted Equipment
0
0
2
2
Structural Calculations
✓
Plumbing Plans
2
Listed and Tested Fire Stopping Assemblies
2
Washington State Contractors License
✓
✓
✓
✓
Contractor's City of Edmonds Business License
✓
✓
✓
✓
Critical Areas Determination or Checklist
l
V/
State Non -Residential Energy Code compliance forms
2
Handouts and Standard Details may be found on the City's website www..edmondswa.gov 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 L:\Building New Folder 2010\DONE & x4erred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014