20160512142430.pdfCity of Edmonds
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A Fax 425.771.0221
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
7722 f. =�,1- �S T 6 tJ - a r a W h� 2 G ' .
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT:
Phone: Fax:
ci ,
424--, ? 79-43691
Address (Street, City, State, Zip):
E -Mail Address;
Z s k46 o-:�
PROPERTY OWNER:
Phone:
Fax:
�t
Address (Street, City, State, Zip):
6{
E -Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*
Phone: Fax:
e �� 'E �,
4 2S 7Li6-6-2
Address (Street, City, State, Zip):
E -Mail Address;
*Contractor must have a valid City of Edmonds business license prior to doing work
WA Statsl n:
N, I #/ Exp, DateV D LA
in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
PLUMBING MECHANICAL1XII TANK
DEMOLITION
DETAIL THE SCOPE OF WORK: s..+�.... �_sA_ ..._:1_tw t.�......... .. .
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: I _ , .e..aOwner [VAgent/Other ❑ (specify): ,
Signature:, _ �� Dater:__..�� d.........u...
FORM C L:\BuiIding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17(2014
PLUMBING
Fixture Type (new and relocated)
Total #
FIXTURE COUNT
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
Equipment Type
Pressure Reduction Valve/Pressure Regulator
BTUs: rmw.�
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Total #
Water Service Line
Gas #.........
Tub/Shower
.Dishwasher_...�.......................................................................................�.�........�_www�
'Other:,,— #.— BTUs: <100k— >100k
Drinking Fountain
.mClothes �...w...,...� �.,,,,
......... ..............
Other:
Air Handler / VAV
Gas #ww_
Washer
Other:, # CFM: <10k, >10k_
Hose Bib
Location(s),._
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Stove/Range/Oven
Water Heater Tankless? Yes ❑ No ❑
a
Hydronic Heat in: Floor ❑ Wall ❑
Dryer
Floor Drain/Floor Sink
Other:
Outdoor BBQ
....vvvW..W_–___w._............................................................................--.....-.------
Refrigerator water supply (for water/ice dispenser)
.�--�------....................... �.....
Other:
Gas #,_
Appliance Type
Appliance/Equipment Information (new and relocated) Total #
AC Unit
BTUs:....._..._.
Equipment Type
Furnace
BTUs: rmw.�
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #.........
Elec
'Other:,,— #.— BTUs: <100k— >100k
Location(s)
......... ..............
Other:
Air Handler / VAV
Gas #ww_
Elec #_,mmmm
Other:, # CFM: <10k, >10k_
Location(s)
Location(s),._
(circle selected)
Stove/Range/Oven
a
f
Dryer
AC / Compressor /
r'
Outdoor BBQ
Boiler / Heat Pump /
Gas #,_
m_mElec #—
Other-- Other- # BTUs: <100k,
100k -500k, 500k-1Mil
Roof To Unit
P
HP:
<3,
3-15, 15-30 Location(s) ....._-.................................._...__
�w,wwm.
(circle selected)
Hydronic Heating
Gas #_Elec
#
In -Floor ,___Wall Radiant— Boiler BTUs:,
_ � Location
Exhaust Fans (single
Bath #
Kitchen # Laundry #
duct)
__w....uw
Fireplace
Gas #
Elec #,.,,-
Other: # Location(s)
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated) Total #
AC Unit
BTUs:....._..._.
Location(s):_.., ------- .............................................__.............-_....................
Furnace
BTUs: rmw.�
............. ..�..._. Location(s)w....... _........ . . .......
._._._..__--...........
Water Heater
BTUs:
W..
Boiler
BTUs:
Location(s):...�........mw......._......----- _ ..........w...
......__,
......... ..............
Other:
BTUs:...._...
_ Location(s)._.... _... _............mmm....
Fireplace/Insert
BTUs:
Location(s),._
Stove/Range/Oven
f
Dryer
r'
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014,docx Updated: 1/17/2014