BLD20161115.pdfDEVELOPMENT SERVICES
M'
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
d s t 121 5`h Avenue N, Edmonds, WA 98020
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 ❑ NN
APPLICANT:
Phone Fax:
Address (Street, Cyity, State, Zip): `` } (/ O ^' yyp (/
® --°6
E -Mail Address:
J 1 F
PROPERTY OWNER;
Phone: Fax,
Address (Street, City, State, Zip)°
E -Mail Address:
LENDING AGENCY:
Phone: Fax:.
%�
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*
Phone: Fax:
Address (Street, City, State, Zip):
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
I .......... 1� mat:, t 1
T ......' �^-Q .t�e�P�... ......
DETAIL THE SCOPE OF WORK ��.�c.2 .......� . `........
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 ....`...._ Ownq�.,w. `Yq
e0/Onter❑(specify):..�� �_...�... ma
Date:
Signature: . . _ ...
FORM C L:\Buildiag New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014
PLUMBINCY
FIXTURE COUNT
MECHANICAL
Appliance/Equipment Information (new and relocated)
Fixture Type (new and relocated)
Total #
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
Location(s) ,,,,
Pressure Reduction Valve/Pressure Regulator
Air Handler / VAV
Sink (kitchen laundry, lavatory, bar, eye wash, etc)
�............ —
„
Elec #
eee....e. ---
Water Service Line
_
____., m._-_ .�. .,... ----------- -
Water Heater
nn
Tub/Shower
(circle selected)
Drinking Fountain
_-_.-._ �..... .......
Dishwasher
Clothes Washer
AC / Compressor /
Hose Bib
Other:„m-...,......
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
BTUs: �w
W.
.. _
Water Heater Tankless? Yes ❑ No
Boiler / Heat Pump /
.. _.�.............. -..�..
Hydronic Heat in: Floor ❑ Wall E]
------ ._-�.
Floor Drain/Floor Sink
Other„
Roof Top Unit
Refrigerator water...........
msupply (for water/ice dispenser)
__<3, ..............................3-15
Other:
..-.,..___—__..............__...m.....�.......e...
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #
Elec #_Other:
#_ BTUs: <100k.— >100k_
Location(s) ,,,,
...._._.�......-.....
Furnace
Air Handler / VAV
Gas #
Elec #
Other: #_________CFM: <10k >10k
Water Heater
(circle selected)
—
Boiler
BTUs:
AC / Compressor /
Other:„m-...,......
BTUs: �w
W.
Location(s)........... m..,., m�w_�.m.. �_._
Boiler / Heat Pump /
Gas #Elec
#_(dthet':.-,.m
m #.._ ...... BTUs: ........<100k, n ..................................
100k -500k, .
Roof Top Unit
HP:
__<3, ..............................3-15
>.............................. 15-30 Location(s)__�w�......................................................
..-.,..___—__..............__...m.....�.......e...
Dryer
(circle selected)
Outdoor BBQ
Hydronic Heating
Gas Rfi. ........Elec
#
.......... In -Floor —Wall Radiant ......... Boiler BTUs:
Location
TOTAL OUTLETS
Exhaust Fans (single
Bath #
Kitchen
# Laundry # . Other ,,,,, __
„w_.. # ,.......e.
duct)
-
Fireplace
Gas #_Elec
#_(?tlret:;
#, l.tacatioir(s)�....
....... ........... ... .. ......
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:
Location(s)-,,,,-._....n..
.._..
...._._.�......-.....
Furnace
.......................
BTUs:......�....�..
Location (s)
Water Heater
BTUs:.
-..._ Location(s):,, ............
Boiler
BTUs:
Location(s):._,,,,
Other:„m-...,......
BTUs: �w
W.
Location(s)........... m..,., m�w_�.m.. �_._
_........_-
Fireplace/Insert
Fire lace/Insert
.............
BTUs. ~ ..
Location(s):. _,,,, ..�
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C LABLIilding New Folder 2010\DONE & x -(erred to L -Building -New drive\Form C 2014.docx Updated: (/17/2014