Loading...
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