BLD20170639-APPROVED PERMIT.pdfO, 1LI
uITY OF EDMONDS
121 5TH AVENUE NORTH -EDMONDS, WA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
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Expiration Date: 11/13/2017
24107 105TH PL W 24107 105TH PL W C/O BRIAN THOMAS
EDMONDS, WA 98020-5725 EDMONDS, WA 98020-5725 19820 10TH PL'W
LYNNWOOD, WA 98036
(2061546=5230 (206)'546-5230 (425)876-5776
VALUATION: $0.00"
PEIZMITAPPROVAL
I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUCTION AND IN DOING THE WORK AUTHORIZED
THEREBY, NO PERSON WILL BE EMPLOYED IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27,,
THIS APPLICATION IS N T A PERMIT UNTIL SIGNED BY THE BUILDING OFFICIAL OR HIS/HER DEPUTY AND ALL FEES ARE PAID,,
/A�io4nato tI Print Name DatePejeOe4;By Date
ATTENTION
ITIS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF
OCCUPANCY HAS BEEN GRANTED,, UBC109/ IBCI10/ IRC110.
ONLINE APPLICANT = ASSESSOR OT11ER
X017-oU3q
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
„S 121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 It 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 #:
2y 101 10 s`"' P c w, EAMMas , WA QF6 zo 005GL1 Q00400aao
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes [:]No
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APPLICANT: Phone: Fax:
►�1 A(J R / N 6, _5 u R(21 S Zvb-! �4bS
-Z30 NIA
Address (Street, City, State Zip): _ E -Mail Address:
2y 10"1 IU5-tK p( W � kmOnL WA qjpOLO Maor'kne_hucs-iS cor C Y)
Alt
PROPERTY OWNER: Phone: Fax„
mAruR► N— 3vRRI's 7-1)(0-54ro Sz30 to /A
Address (Street, City, State, Zip):E-Mail Address: IL
:U410-) 10! `^ Pt k), 1 p .9026 Maurine_burr", eAs A4v
�I'tNl G AGENCY: Phone: Fa
esti (Street, City, State, Zip): E -Mail ess:
Co) "ERACTOR:* Sri CYtn Phone: Fax:
aft %i h (O nrM �'-- -T 25' 8716 -5_n
Address (Street, City, State, Zip): E -Mail Address:
►O 10 4 1 L nnWwd UTA 03(o Sk,/) C4 um6l,nei a, cow,
*Contractor must have a valid City of Edmonds business license prior to doing work 6 0 � to 1to l a x/1.1 . gate.,/ S
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
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.
Print Name:,,,,,,(4Ur L Urrl S Owner V Agent/Other ❑(specify):
a r r
/J___...
Signature: m Date: �%,� l�
FORM C L:\Building New Folder 2010\DONE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014
M
X
Fixture Type (new and relocated) Total #
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
_
Furnace
Pressure Reduction Valve/Pressure Regulator
Elec #,Other:
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
# BTUs: <100k_ >100k_
Water Service Line
Air Handler / VAV
(circle selected)
Tub/Shower
m_
........._
Drinking Fountain
# CFM: <10k >10 _
Dishwasher
BTUs: Location(s): ,,,,,_ _
Clothes Washer
Stove/Range/Oven
..... ............ _
Hose Bib
............
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
. ............
Water Heater Tankless? Yes ❑ No ❑
Boiler / Heat Pump /
Hydronic Heat in: Floor ❑ Wall ❑
#_Other:—
Floor Drain/Floor Sink
# BTUs: ...................................
Other: ° Q
Refrigerator water supply (for water/ice dispenser)
HP:
Other:
3-15, 15-30
Equipment Type
Appliance/Equipment Information (new and relocated)
BTUs: Location(s):, W_
Total #
Appliance/Equipment Information (new and relocated) Total #
Furnace
Gas #
Elec #,Other:
_
# BTUs: <100k_ >100k_
Location(s)_, . .......
Air Handler / VAV
(circle selected)
Gas #
Elec #
Other:,._ „--,.
# CFM: <10k >10 _
Location(s)----,,,
BTUs: Location(s): ,,,,,_ _
AC / Compressor /
Stove/Range/Oven
Dryer
. ... . .... ......
Boiler / Heat Pump /
Gas #_Elec
#_Other:—
# BTUs: ...................................
100k -500k, 500k -Mil
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
# #
#
duct)
........................Laundry
_Other:
Fireplace
Gas #.......
-Elec #„,,Other:
#i Location(s)_......
Dryer Duct
Appliance Type
AC Unit
Appliance/Equipment Information (new and relocated)
BTUs: Location(s):, W_
Total #
Furnace
BTUs: ,_......... Location(s):
Water Heater
BTUs: _... _,m ______Location(s):
Boiler
BTUs: _ Location(s):
Other:
BTUs: _ Location(s):
Fireplace/Insert
BTUs: Location(s): ,,,,,_ _
Stove/Range/Oven
Dryer
. ... . .... ......
Outdoor BBQ
...... ........
TOTAL OUTLETS loll
el
FORM C LABuilding New Folder 201000NE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014