BLD20170459.pdf.11 c V h.
DEVELOPMENT SERVICES
�"r PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
tyM t l 121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 11 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 #:
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Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No [—]
APPLICANT:
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Phone: 4c
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Fax:
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Address (Street, City, State, Zip):
E -Mail Address: 6-0c,'
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PROPERTY OWNER'
C' P ( � (pi -,Fax:
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�Phone:
Gii� 7 . &
Address (Street, tity, State, Zip):
E -Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*
Phone: Fax:
Address (Street, City, State, Zip):
E -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. Dater
PLUMBING MECHANICAL TANK
DEMOLITION i
DETAIL THE SCOPE OF WORK I I &C L k_VA_ �Gt_S S C mn n P C 1
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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: l . .'' Owner "Agent/Other ❑ (specify):
_..
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S'iglaatw�rek, � 1-y.444 ��a � ,.� �. '���� � Date:
FORM C LABuilding New Folder 2010\130NE & x-ferred to L -Building -New drive\Form C 2014.doex 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. RBPA, DCDA, AVB)
Water Heater Tankless? Yes ❑ No ❑ Hydronic Heat in: Floor ❑ Wall ❑''
Floor Drain/Floor Sink Other:
Refrigerator water supply (for water/ice dispenser) Other: rl
E
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
MECHANICAL
Appliance/Equipment Information (new and relocated)
in
Total #
Furnace
Gas #,.--Elec
#_-Other:.—
#� BTUs: <100k, >100k_
Location(s)
BTUs: Location(s):
Air Handler / VAV
Gas #_Elec
#_0ther:
# CFM: <10k >10k
Location(s)
BTUs: Location(s):
(circle selected)
Fireplace/Insert
BTUs:. _ Location(s):—
Stove/Range/Oven
AC / Compressor /
Dryer
Outdoor BBQ
Boiler / Heat Pump /
Gas #_,,,__Elec
#
Other: _ # BTUs: <100k,
100k -500k, 500k-1Mil
Roof Top Unit
HP • .............................
<33-15
>............................. Location(s).._........._..__..........._._._...............
..._......-__
(circle selected)
Hydronic Heating
Gas #—Elec
#_In
-Floor _Wall Radiant,_„ Boiler BTUs:
Location------ .................... IT
Exhaust Fans (single
Bath #_Kitchen
#_Laundry # Other:,
duct)
............ _#_ITITITITIT.
Fireplace
Gas #......–Elec
#—._.0titer:—....mm-.......__
#........ Location(s). ..... .........
.........
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:
......... _.
Furnace
BTUs: , Location(s):.
Water Heater
BTUs: Location(s):
Boiler
BTUs: Location(s):
Other:
BTUs: 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 driveTorm C 2014.docx Updated: 1/17/2014