BLD20161248.pdfCity of Edmonds
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A Fax 425.771.0221
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
Q ,
, y State, Zip) "r,11,10,
PROJECT ADI II'L,S�a (Street Suite # Cit �p
Parcel #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT: C__ �
Ph o e:
Fax:
SMV1 w
At°1t1M°CS! (Street C,ty, Stet c, Zip):
-Mail Address:
W
�Y\
PR0j4RTY PWNER:
Phone: Fax:
Address (`� beet °ty, State. Zip).
E -Mail Address:
V
LENDING A ENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:* ®
Phone:
Fax:
...
�Ic11cs;� (`� trees, Ci .`ate,
l Zip). � �
ail Address
� )
� �
WA State License #/Exp. Date:
�� prior to doing work
Contrac or must have a valid C'k of Edmonds business license
in the City. Contact the City Clerk's Office at 425.775.2525
1 City Business License #/Exp. Date:
PLUMBING I I MECHANICAL L ,,,,,f, TANK DEMOLITION
DETAIL THE SCOPE OF WORK:
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. m..
Print Ntt1t-ae _.. m -- Owner ❑ Agent/Other [T(specify)� .........
.� ...
Sig1t<(tlra� Date:
FORM C L:\Building New Folder 2010\DONE & x-ferred to [Building -New drive\Form C 2014.docx Updated: 1/17/2014
# PLUMBING FIXTURE COUNT
Fixture Type (new and relocated) Total # Fixture Type (new and relocated) Total #
Water Closet (Toilet) Pressure Reduction Valve/Pressure Regulator
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.) Water Service Line
Tub/Show ... ...........___ .. ..._,._._.
er Drinking Fountain
Dishwasher_—....._.... W....__ _ ........
Clothes Washer
Hose Bib Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water YHeater ❑....._ _-_-......_ y ....._�. .�. -
Tankless? Yes No H dromc Heat in: Floor Wall ❑
Floor Drain/Floor Sink Other:
Refrigerator water supply (for water/ice dispenser) _ Other:
Equipment Type
BTUs: �m..
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #Elec
#_Other:
# BTUs: <100k >100k_
Location(s)._„ _,_,---_ - ,.
Water Heater
Air Handler / VAV
Gas #_Elec
#_Other:
#CFM: <lOk,,,,,,,,,,,,,,_ >lOk_
Location(s) ,..........
(circle selected)
Location(s)w_.—.,,,...........—..w . -... .,..... __.—...... -_.....�..._..�
............................................................ ........................
BTUs:.....m. _
AC / Compressor /
Fire la c e/Insert
p
BTUs:,, . -....w..
Location(s):,
Boiler / Heat Pump /
Gas #Elec
#
Other:________ # BTUs_.................__<100k, _ _
---------- 100k -500k, 500k-1Mil
Roof Top Unit
HP:. ..............<3,
w
._._._.__.3-15, ._._. _...__..15-30 Location(s)
Outdoor BBQ
(circle selected)
Hydronic Heating
Gas #
Elec #_In
-Floor _Wall Radiant,...,.__ Boiler BTUs:
Location—_--__._.,–,,
Exhaust Fans (single
Bath #---------Kitchen
9P # _ em... Otlaa t t.ew___– _......._.. �...�.....m�
... ......... .m.__.# .._.
duct)
------Laundry
Fireplace
Gas #Elec
#_Other:
#_
Dryer Duct
Appliance Type Appliance/Equipment Information (new and relocated) Total #
AC Unit
BTUs: �m..
_. Location(s):.......— ...n .�--
_
Furnace
BTUs: _.—�.w...,. �.........._
Location(s):__,,.,_--.. _
Water Heater
BTUs: ..—,..... .. �m
Location(s)-,,. ......,. _. _. w _ .. .w.-, _......� ,_.
Boiler
BTUs:.w..� ...
Location(s)w_.—.,,,...........—..w . -... .,..... __.—...... -_.....�..._..�
Other —�._
BTUs:.....m. _
_.. Location(s),
Fire la c e/Insert
p
BTUs:,, . -....w..
Location(s):,
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 201000NE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014