BLD20161524.pdfPLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
OJ
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
PERMIT APPLICATION
APPLICAN' "
121 5th Avenue N, Edmonds, WA 98020
AVtess (Street, Cit , State, Zip);
Phone 425.771.0220 ft Fax 425.771.0221
City of Edmonds
Phone: Fax:
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
OJ
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICAN' "
Phone:, tx:
74k
AVtess (Street, Cit , State, Zip);
E -Mail Address:
Pik, 1 � R"'� 'Y O"Nr�°'NER:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:.
LENDING AGENCY:
Phone: Fax:
Ad ss (Street, City, State, Zip):
E -Mail Address:
CO, YRACTO Rw4°
Phone: Fax:
Address (Street, City, State, Zip):
-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
DETAIL THE SCOPE OF WORK v'..,Y.1..a ..� .......
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 ❑ (specify):
._.............................. _ _ ....
Signature: _ Date:
FORM C LABuilding New Folder 2010\130NE & x-ferred to L Building -New driveTorm C 2014.docx Updated: 1/17/2014
PIAMBING.
Fixture Type (new and relocated)
FIXTURE COUNT
Total # Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
Pressure Reduction Valve/Pressure Regulator
Furnace
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Water Service Line
# BTUs: <100kJ„>100k_
Tub/Shower
Drinking Fountain
Air Handler / VAV
Dishwasher
Clothes Washer
Other: #,CFM: <lOk >10k
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
(circle selected)
Water Heater Tankless? Yes ❑ No ❑
Hydronic Heat in: Floor ❑ Wall ❑
_
Floor Drain/Floor Sink
Other:
AC / Compressor /
Refrigerator water supply (for water/ice dispenser)
Other:
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas#—Elec#—Other:
BTUs: Location(s): ____ .
# BTUs: <100kJ„>100k_
Location(s),
BTUs: Location(s)........ �,____ITITIT
Air Handler / VAV
Gas #_
Elec #_,,,,,
Other: #,CFM: <lOk >10k
Location(s)
BTUs: _..... Location(s):
(circle selected)
Other:
BTUs: .._IT. Location(s):
_
Fireplace/Insert
BTUs: Location(s):
AC / Compressor /
Stove/Range/Oven
Dryer
........ ............. ........ ... _ .... .._....._..... .._ .
Boiler / Heat Pump /
Gas #_ww,
„Elec #,
Other:, ,_ # BTUs: <100k,
100k -500k, 500k-1Mil
TOTAL OUTLETS
Roof Top Unit
HP:
<3,
3-15, 15-30 Location(s)
(circle selected)
Hydronic Heating
Gas #
Elec #,
In -Floor _......... .Wall Radiant-- Boiler BTUs:
Location
Exhaust Fans (single
Bath #_Kitchen
#_Laundry #
#_
duct)
........Other:
Fireplace
Gas #_Elec
#_Other:
#_ Location(s).
...............................................
Dryer Duct
FORM C LABuilding New Folder 2010\DONE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s): ____ .
Furnace
BTUs: Location(s)........ �,____ITITIT
Water Heater
BTUs: . Location(s):
Boiler
BTUs: _..... Location(s):
Other:
BTUs: .._IT. Location(s):
Fireplace/Insert
BTUs: Location(s):
Stove/Range/Oven
Dryer
........ ............. ........ ... _ .... .._....._..... .._ .
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\DONE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014