BLD20160837.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5 1h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft 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 #:
2- 05 c 4512,5 s 4:Fcj VKO A ,Z,
ca3 Z. i Z- I Lyng
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes F] No Er
APPLICANT:
ON05 LJ P.QLI�5 F=,Md41-
Phone:
Address (Street, City, State, ft OF
E -Mail Address:
6�13z- Ljllw,116.1�-
PROPERTY OWNER:
Phone:
Fax:
, Ce_j"4e_ij
k-�&j:L k- L�r
I
mack
Address (Street, City, State, Zip :
E -Mail Address:
LQ'i Ck-k-00-N S+ dZIM!L46 &M Z-.
LENDING AGIENCY:
Phone:
ax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*
Phone:
�Z�,-SZJ- 13-3-3
Fax:
1
Address (Street, City, State, Zip): U
E -Mail Address:
�.Lg L "it as, wK 6e -Lo,
WA State License #xp. Date: "
*Contractor must have a valid City of Edmonds business license prior to doing work
ALL q jQ�gjjin
the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date: '
1,4/9, -oz-" I? (2. 3
PLUMBING MECHANICAL TANK I
I DEMOLITION I I
DETAIL THE SCOPE OF WORK: 674-S ® ]Pi'!3 +0 61-r, VTv"e,,
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: 0,k5, L
o&vv-" Owner [:1 Agent/Other 011(specify):
L/
Signature: Date:
FORM C LABuilding New Folder 2010\70NE & x-ferred to L'Building-New drive\Form C 2014.docx Updated: 1/17/2014
PLUMBING
FIXTURE COUNT
MECHANICAL
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
Furnace
Pressure Reduction Valve/Pressure Regulator
Total #
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Gas #_Elec
Water Service Line
Boiler
Tub/Shower
Location(s)
Drinking Fountain
Air Handler / VAV
Dishwasher
#_Other:
Clothes Washer
#_CFM: <10k_ >10k_
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Dryer
Water Heater Tankless? Yes ❑ No ❑
Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink
AC / Compressor /
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Fonn C 2014.docx Updated: 1/17/2014
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
Equipment Type
Furnace
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #_Elec
#_Other:
Boiler
# BTUs: <100k_ >100k_
Location(s)
Other:
Air Handler / VAV
Gas #_Elec
#_Other:
BTUs: Location(s):
#_CFM: <10k_ >10k_
Location(s)
(circle selected)
Dryer
Outdoor BBQ
AC / Compressor /
TOTAL OUTLETS
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 #
#
duct)
_Other:
Fireplace
Gas #Elec
#_Other:
# Location(s)
Dryer Duct
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Fonn C 2014.docx Updated: 1/17/2014
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s):
Furnace
BTUs: Location(s):
Water Heater
BTUs: 4y, C Location(s):
Boiler
BTUs: 4W k Location(s):
Other:
BTUs: Location(s):
Fireplace/Insert
BTUs: Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Fonn C 2014.docx Updated: 1/17/2014