BLD20160838.pdfAt L
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5"' Avenue N, Edmonds, WA 98020
est. t R9� Phone 425.771.0220 A 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 #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No]
APPLICANT: ^�d
Phone: 7 Fax:
Address (Street, Stat "Zip
2L I CR) L�I Cy"
-Mail Addre ; :
0
PROPERTY O ER:
2-ve_,� Sk Le
Phone: Fax:
L:�:
Address (Street,y,State Zip): w
y E -Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:* (p�
L�01(VIV,
y Phon :
Fax:
Address, (Street, City, Std e, p):
(20 Z5 kF LL��rv_t:
E -Ma 1 Address:
W SI Licegse #/ x pate:
9-
*Contractor must have a valid City of Edmonds business license
prior to doing work &
in the City. Contact the City Clerk's Office at 425.775.2525City
B siness License #/Ex Date:
PLUMBING MECHANICAL TANK DEMOLITION
FDETAIL'I'IIE �IL �(
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SCOPE Or WORK: 1V
i F- e�t
I declare under penalty peq*ury l tws that the information I have provided on this form/application is true, correct and complete,
and that I am t�a� )per y owner r duly authorized agent of the property owner to submit a permit application to the City of
r
Edmond(e::
Print Na 7
Owner AgentlOther El(specify):
Signatur
Date:
FORM C L:ABuilding New Folder 2010vDONE & x-ferred to I. -Building -New driveAForm C 2014.docx Updated: 1/17/2014
�I
P1.11MI1INC. FIXTURE 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. Rt;eA, oCnA, AVB)
Water Heater Tankless? Yes ® No ❑
Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
Equipment Type
BTUs:
Appliance/Equipment Information (new and relocated) Total #
Location(s):
BE a
Appliance/Equipment Information (new and relocated) Total #
Furnace
Gas #_Elec
#--Other:
# BTUs: <100k-- >100k_
Location(s)
Air Handler / VAV
Gas #_Elec
#_Other:
#_CFM: <10k_ >10k_
Location(s)
(circle selected)
Fireplace/Insert
BTUs:
Location(s):
Stove/Range/Oven
AC / Compressor /
Dryer
Boiler / heat Pump /
Gas #_Elec
#_Other:
# BTUs: <100k,
100k -500k, 500k-IMil
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
AC Unit
BTUs:
Appliance/Equipment Information (new and relocated) Total #
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 OUTLETS
FORM C L:ABuilding New Polder 2010AI00NE & x-ferred to Ld Adding -New driveTorm C 2014.docx Updated: 1/17/2014