BLD20161101.pdfa DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5h 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 #:
�N.�Nbi, WA
W!> o 3 ZyL4 T11
00S9-7 1 D000 o GO o
ANOTHER PROJECT? Yes Nox""
Associated Permit #:
IS THIS WORK ASSOCIATED WITH
APPLICANT: /� 1 V�-SIC_ �rQ�t�I cA rp (z S , I /V C .
Phone: Fax:
7Ak.-71. Z, - 7.roa Zo6.76Z•7757
Address (Street, City, State, Zip):
E -Mail Address:
S1 S, S. ST 5 CA-T-T,_e_, w A, °1 Ps 10 46
LA A VcK X00 , co w`
PROPERTY OWNER:
Phone: Fax
I(-A,K-e.► G-,����sp�E_
Zo6•S-' 2-87q�
Address (Street, City, State, Zip): �o,�1Sc� w A
E -Mail Address:
1 0 3 0 3 Z `{ 94 T" ST S� �� f, O 'ZO
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:* N \ V &A -S Arcs 7K 1b. PL� t c A mf- S , x N C_
Phone: Fax:
17_o(,
701,•767 • 7SOb -7G2 . 7757
Address (Street, City, Stale, Zip):
o+w.,�"�""'t�. J� ��iT'7 7 �L W,4- l O t a g
E -Mail Address: /� 1
%A o i - le- L-3 VD. 4-n tl �O ✓�`
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
(oo l 7 3 '7" 2 Sr / t 2
in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
Nr--- ozzpia I z/ I I 2olc,
i
PLIJMI3ING MECHANICAL TANK 1XI
DEMOLITION
\
DETAIL THE SCOPE OF WORK: _ ,ANI,,,�.,,,.SS
11 �
l H'�JJ T 1 Pk t t L_ Ok..............�.L
A IVB PJ l_l. .
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: ' Owner Agent/Other (speeify): ConlT""'C�dyL—
Signature: v Date: 1
FORM C LABuilding New Folder 2010\DONE & x4erred to L -Building -New drive\Form C 2014.doex � Updated: 1/17/2014
Type of Gas/AirNacuum System (new and relocated) 7Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical - Surgical Vacuum
Other:
TOTAL OUTLETS
�10 0131111
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
... .- ._ ......... ....... ... .................
IFillinPlaceXFill Material FOA N\ Fill in Place ❑ Fill Material
................... ..
Removal ❑ Removal ❑
.......... . ............ ......
Number of Gallons:&, . _ Number of Gallons:
Critical Areas Determination: Study Required ❑ Conditional Waiver Waiver
Type of structure to be demolished (e.g. house, shed, garage, etc.):
......._._... _....... _...........
_._
Floor area of structure to be demolished: sq. ft.
❑ mm
...........................................
Critical Areas Determination: Study Required Conditional Waiver ❑ Waiver
❑
PSCAA Case No. AHERA Survey done? (required) ❑
Additional comments:
FORM C L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
City of Edmonds
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT CHECKLIST
1215"' Avenue N, Edmonds, WA 98020
Phone 425.771.0220 Q Fax 425.771.0221
PROJECT ADDRESS: (03.03 2 q q r' ST` S LJ
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.
A
2
SUBMITTAL REQUIREMENTS
°
CDd
Y
The number indicates the number of copies for submittal( if
W
applicable). Check marks indicate additional submittal
°= m
■-
fD
O
requirements that may apply to your project.
o
...__...
A.. ....._.-.. ..............................
Application Form C
1
1
.. ._
.....................................................
1 1
........ __ -- .......
................._.... ....._..
............._._........
Site Plan
3
1
..............................
_...
Mechanical Plans
_ _
.................. ............ ..._...._..._.
2
............ .......
m... -. ......_......... _....
Manufacturer's Specifications/Cut Sheets
0
0 _
_........ _....._ _. __ ...._
2 2
_.............................
....... �..---------
Elevation View fo....._.�._.
r Roof Mounted Equipment
0
0
2 2
-
__._ _.......
____.._..._..
Structural Calculations
✓
Plumbing Plans
�
_.._
_— ...........
_.
..... .... _._ w.... ........�
2
_ ................. --_--.--
.....
..�...-.. .................
.. ...
Listed and Tested Fire Stopping Assemblies
2
_.......__...._
_.....uu.............. _.� ..
Washington State Contractors License
✓
......
✓
.............._ .__.......
✓ ✓
Contractor's City of Edmonds Business License
✓ _✓
✓
Critical Areas Determination or Checklist
1
✓
State Non -Residential Energy Code compliance forms
2
• Handouts
and Standard Details may be found on the City's website
Nvww.edmoTidswp,,Lqy
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 LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
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