BLD20161410.pdfCity of Edmonds
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
1215 1h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A Fax 425.771.0221
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
E e $ozo
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT?Yes No
Associated Permit #:
APPLICANT: Sate "e\�� �„��
Phone: Fax:.
75-2-5-7
Address (Street, City, State, Zii1):
k'9(-a9-,����, .� W TS033.
E -Mail Address:
PROPERTY OWNER:
Phone:
Fax„
n%"%r`Ne. 5 c-
425 -77'9
Address (Street„ City State, Zip):
E -Mail Address:
W\, &) Sr vnov A
LENDING AGENCY:
Phone: Fax:
7
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:* �Qta�� C_QUX'� Q\c�LW���e�c�
Phone: Fax:
J �%7%
Address (Street, City, State, Zip):
E -Mail Address:
WA State License Ii/hixp, Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
oU V a �2 �z —3o
in the City. Contact the City Clerk's Office at 425.775.2525
Cil Business License #/Exp. Date:
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PLUMBING MECHANICAL TANK Lj
DEMOLITION
DETAIL THE SCOPE OF WORK: „n,...y�" .,..,._ r%....... ,,,__...C'��
., ° --_ C C ..... __. v........A��....... ^Y��'S� 1111 ��._._._. `._._. .._. �.� ��..._ 0.6 ll��-........��,
I
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 properly owner or duly authorized agent of the property owner to submit a permit application to the City of
Edmonds.
1
Print Name: �t..� �ITITITITIT Owner 0 AgcntPOlhct. (specify): .... .................
Signature:._..... Date:
_
FORM C LABuilding New Folder 2010\130NE & x-ferred to L -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/Shower Drinking Fountain
Dishwasher Clothes Washer
....
......... .. - _ . .... _..._ ._
Hose Bib Backflow Prevention Device (e.g. BBrn, ncnn, AVB)
Water Heater�Tankless? Yes ❑ No ❑ Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink Other:
Refrigerator water supply (for water/ice dispenser) Other:
FORM C L:\Building New Folder 2010\DONE & x-ferred to L Building -New drive\Fonn C 2014.docx Updated: 1/17/2014