BLD20161613.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5b 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 #:
19703 84th Ave W, Edmonds, WA 98026
00558700001100
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? YesF—]No®
PPLICANT:
ilco Company Inc.
Phone:
206-547-8347
FP
548-9352
Address (Street, City, State, Zip):
E -Mail Address:
PO Box 31228 Seattle, Washington 98103
info@filcoenviro.com
PROPERTY OWNER:
Christo2her Moore
Phone:
206-735-1664
Address (Street, City, State, Zip):
E -Mail Address:
19703 84th Ave W, Edmonds, WA 98026
chris.moore.builde mail.com
LENDING AGENCY:
Phone:
tax -
Address (Street, City, State, Zip):,
E -Mail Address:
CONTRACTOR:*
Phone:
Fax:
Filco Company Inc.
206-547-8347
[06-548-9352
Address (Street, City, State, Zip):
E -Mail Address:
PO Box 31228 Seattle, Washington 98026
info@filcoenviro.com
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work FILCOCIO80RU
in the City. Contact the City Clerk's Office at 425.775.2525
1 City Busmess License #/E
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INR -02053,3 1 016
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PLUMBING MECHANICAL
TANK I./ DEMOLITION
DETAIL THE SCOPE OF WORK: Pump out, excavate and remove one 300 gallon residential
heating oil tank. Back fill excavation, haul tank away and properly dispose of tank.
I declare under penalty of perjury laws that the information I have provided on thisforrWapplication is true, correct and complete,
and that l am the property owner or duly authorized agent of the
property owner to submit apermit application to lite City of
Edmonds.
Print Name: l 7
Owner 0 Agent/Other F (specify): Contractor
Signature: C
Date: 7,A/ —zL,2 o i
0M
FOR M C. I -\R,ifld;no Vp— Pnleir ')Al 0MOVP R. —f—pd to T -Pvi;1d;na-NT--4A—\T7— f")nl A A— I I
Type of Gas/AirNacuum System (new and relocated) Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon dioxide
Helium
Medical — Surgical Vacuum
Other:
TOTAL (OUTLETS
TANK #1
TANK #2
Method of Abandonment
Method of Abandonment
Fill in Place
Additional comments:
Fill Material
Fill in Place
Fill Material
Removal ,�
Number of Gallons: 300 gallon
Removal
Number of Gallons:
Critical Areas Determination: Study Required
Conditional Waiver [] Waiver
CRA 19930060
NMIDEMOLITION
Type of structure to be demolished (e.g. house, sbed, garage, etc.):
Floor area of structure to be demolished: sq. ft.
Critical Areas Determination: Study RequiredQ Conditional Waiver E Waiver F
PSCAA Case No.
AHERA Survey done? (required) [�
Additional comments:
FILCO COMPANY INC. LICENSE#FILCOCI080RU EXP:10/10/2017
PO BOX 31228 ICC LICENSE # 8145449
SEATTLE, WA 98103
SITE PLAN
HEATING OIL TANK DECOMMISSIONING
JOB SITE ADRESS: 19703 84th Ave W, Edmonds, WA 98026
OWNER: Christopher Moore
PHONE: 206-735-1664
ACTIVITY: Excavate and remove, one 300 gallon residential heating oil tank. Back fill hole and properly
dispose of tank.
O 45„
concrete patio
115"
19703 —house
i
driveway
84th Avenue West