BLD20170412.pdf)MONDS
)MONDS, WA 98020
X:(425)771-0221
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City of Edmonds
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DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 It Fax 425.771.0221
„W , �?ASE' REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT '° ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
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JCDT r � 'EOVAI Lt&D l �,J
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes No ❑
APPI ICA NT:
Phone: Fax:
Address (Street, (74y, State, Zip):
E -Mail Address:
PERTY O NE3t-
P
„
Phone: Fax„
Address (Street, City, State, Zip):
E -Mail Address:
a,�,
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LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
(TOR:*
I AIA &11
(feet, City State Zip):
*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
PLUMBING I I MECHANICAL TANK
Phone: LL
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E -?t Address:......
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WA State License #/Exp. Date: /—/7
Cit Business License 11' . DaW
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DEMOLITION
DETAIL THE SCOPE OF WORK: t l t..... v_. -t ° (.�.m,— ............... _.........
CA-, Xwo'k,-v- mm..__. ........ _....�.....__
I declare under penally 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 Natn . �k JN r m. _ ... 0, . `❑ Agent/Other ❑ (specify): Vl V M6
Sig11:t1t11° _ .mate: �....
NORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New driveTorm C 2014.doex Updated: 1/17/2014
Fixture Type (new and relocated) Total # Fixture Type (new and relocated) Total #
Water Closet (Toilet) Pressure Reduction Valve/Pressure Regulator
- m ...................
� �....w.�- _............ ..... a_ ....�_. �........
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. RBPA, DCDA, AVB)
......... ............ _ _ ............
Water HeaterTankless? Yes ❑ No ❑ Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink Other:
ww____....._ _
-
Refrigerator
Refrigerator water supply (for water/ice dispenser) Other:
j —11 — - — ------- ---
Equipment Type Appliance/Equipment Information (new and relocated) Total #
Furnace II Gas # Elec #_Other: # BTUs: <100k_ >100k Location(s)
Air Handler / VAV
Gas #_Elec #_Other: # CFM: <10k_ >10k_
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Gas #_Elec #_Other:. ............. # BTUs:....... .........<100k, _100k -500k, .................-500k-1Mil
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 # +f')ther:...w......-�_�a...ww_....----...�
duct)
Fireplace I Gas #_Elec #_Other: # Location(s)
Dryer Duct
FORM C L:\Bui[ding New Folder 201 HONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014