ENG20170367.pdfCITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDS, WA 98020
PHONE: (425) 771-0220 - FAX: (425) 771-0221
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STATUS: ISSUED 03/17/2017
BUILMN(y
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Expiration Date: 09/18/2017 �
8521 MAPLEWOOD LN
EDMONDS WA 98026-6342
(425)778-0898
Repair Water Service Line
VALUATION:$0.00
8521 'MAPLEW OOD LN
EDMONDS, WA 98026-6342
(425)778-0898
C/U LOUISE HANSEN
2442 NW MARKET, ST STE 455
SEATTLE, WA 98107
(206)617-4567
LICENSE #: WEEZEPI92SCI EXP 02/21/2018
gni nHi,ni�vi nom:
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,
1113S APPLICATION IS NOT A PERMIT UNTIL SIGNED BY THE BUILDING OFFICIAL OR HIS/HER DEPUTY AND ALL FEES ARE PAID.
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lgllalu Rin(`Name Date- Released By Date
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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/ IBC110/ IRC110.
EONLINE APPLICANT = ASSESSOR OTHFit
D
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft 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 #:
S 2-I YyN e-, p lew ood Lexie dal m ods f wll
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLI T: Phone: y Fax:
.� C_ Fournier yz)
Address (Street, City, State, Zip): E -Mail Address:,
S,',S Z-1 ✓na pie t visor/ 1-06-\f-n•+�� Iz✓�n t@
PRO=TY OWNER: Phone: Fax:_
Address (Street, City, 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): U 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. Date:
PERMIT APPLICATION F()Rt
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK —47,67
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_... _._�._ ._...'"� _ . _ _� fir" r �m...m" /�. ............... ... .. ...... .._ .a.......... ...... .._.. ...............m
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 El (specify)-
Date:
s ecifDate: �_.�.. '_ ............
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx 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
J.
d�www.. _..�.... �.
Tub/Shower Drinking Fountain
w .... ....._.m ...._ .. _....._..
Dishwasher Clothes Washer
Hose Bib ... ...
.............��......��_... Backflow Prevention Device (e.g. BBPA, DCDA, AVB)
Water Heater Tankless?ITYes � No .........m..�. �-_.... H dronic Heat in. F� � ._ITITITm�T� �..__...
................. ..............r
❑ ❑ y loor ❑ Wall ❑
Floor Drain/Floor Sink Other:
..........
Refrigerator water Supply ........... �....... � ._ _..__..��_.� _ .. m� �_.._.........w...._
g pp y (for water/ice dispenser) Other:
Equipment Type Appliance/Equipment Information (new and relocated) Total #
Furnace I Gas # Elec #_Other: # BTUs: <100k_ >100k_ Location(s)
Air Handler / VAV
Gas #_Elec
#_Other:
#_CFM: <10k_ >10k Location(s)ITmm,,,,
(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) w,,,,,
(circle selected)
Hydronic Heating
Gas #
Elec #_In
-Floor _Wall Radiant_ Boiler BTUs:_ .............. Location-,.-_,.----,,,,_
Exhaust Fans (single
Bath #_Kitchen
#_Laundry #.___.._._....... _(ltltl
.......-�........
duct)
Fireplace I Gas #_Elec #_Other: # Location(s)
Dryer Duct
FORM C LABuilding New Folder 2010\DONE & x -ferrel to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014