20160615.pdfMz 0
cn DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
t St l� 121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 A Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
J
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ N
APPLICANT:
Address (Strcct t�`t,y, Suite, Zip):
t-
l" P ARTY )'lt?l� N f
Address (Street, City, Stalc, Zip):
�.
LE ING AGEN Y:
Addre treet, City, State, Zip).:
CONTRACTOR * -. ( �
Address (Street, City, State, Zip):
*Contractor must have a valid City o f Edmonds business license prior to doing work
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING I I MECHANICAL II T
Parcel t
Associated Permit #:
�m
Had Address: ,
1'11 1 e: Fa
E-Mail Address:
Phone: Fax:
E-Mail Address:
Phone: F
E-Mail Address:
WA State License #/Exp. Date:
City Business License 4/Exp. Date:
DEMOLITION
DETAIL THE SCOPE OF WORK:....'... .............
--... ............. .....�,..m _.......__.��._�
]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 N� � "' � ,.,
f 1 m, Owner Ej Al entf(ltl (specify): ..
_...
qw
Signal .c .� . m._ Date:
9
FORM C LABuilding New Folder 2010\DONE & x-ferred to LrBuilding-New drive\Form C 2014.doex Updated: 1/17/2014
Fixture Type (new and relocated) ffTotal 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. RDPA, DCDA, AVB)
Water Heater Tankless? Yes ❑ I ❑ Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink Other:
Refrigerator water supply (for water/ice dispenser) Other:
Equipment Type
Furnace
Air Handler / VAV
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Roof Top Unit
(circle selected)
Hydronle Heating
Exhaust Fans (single
duct)
Fireplace
Dryer Duct
Appliance Type
AC Unit
Furnace
Water Heater
Boiler
Other:
Fireplace/Insert
Stove/Range/Oven
Dryer
Outdoor BBQ
Appliance/Equipment Information (new and relocated) Total #
Gas # Flee # Other: # BTUs: <100kZ >100k Location(s)
Gas # Elec #_Other: #CFM:
Gas #_Elec #_Other: #
HP: <3, 3-15, 15-30 1,4011,11
>10k. Lo tioaa(s).
<JNk, 100k-500k, 500k-1Mil
Gas #,.. f lec il. ,lax- Flour _Wall adiant_ Boiler BTUs:.... __. I ovation
Bath #--Kitchen #_ -.�,, Laaaund
Gas # Elec # Other:, — # ........_ L o atjon(s)_.. .....�_���.m.
Appliance/Equipment Information (new and relocated)
BTUs: _._
Location(s):
�....._.. M
BTlN: _
m
Location(s): _w
Location(s):_
�......
IITI' .,
I ocation(s):
'17 Is:
l,ocation(s):
lI" U
Locatiot a(s):
AL OUTLETS
Total #
FORM C LABuilding New Folder All HONE & x-ferred to L-Building-New driveTorm C 2014.docx Updated: 1/17/2014
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
Fill m Rid1t F' -Fill in Place Fill Material
ill Material _ ! I_� �¢�._ ❑ ial
Removal ❑ Removal ❑
+r� _ f Gallons:
Number of Gallons: 4 .. Number o.. .
Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑
FORM C L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT CHECKLIST
121 51s Avenue N, Edmonds, WA 98020
St. I Phone 425.771.0220 9 Fax 425.771.0221
City of Edmonds
PROJECT ADDRESS:
Plans shall
be of sufficient clarity to indicate the location, nature, and extent
of the work
proposed,
and conform
to the provisions
of
the adopted
International Codes and City Ordinances.
_...... ................. .......
..
O
SUBMITTAL REQUIREMENTS
=
w
The number indicates the number of copies for submittal( if10
..fDi
applicable). Check marks indicate additional submittal
a
requirements that may apply to your project.
k
zjhctllfon Form C
1
1
1
1
_..._
Site Plan
_�.........
3
1
Mechanical Plansa..�_
.....
._W_.... .
Manufacturers 4pecalicttaonslt't11 Sheets
0_
0
2
2
Elevation View for Roof Mounted. Equipment
0
0
2
2
Structural Calculations
_..
✓
Ylumbin 7Plans
2
...
Listed and Tested Fire Sto in A
pp ssemblies
-�
2
Washington State Contractors License
✓
✓
s/
✓
-Contractor's Cil of Edmonds Bus .._
y iness License
_
✓
....._
✓
✓
_..�
...
Critical Areas Determination or Checklist
l
✓
State Non -Residential Energy Code comp .......m......
.fiance forms
• Handouts
and Standard Details may be found on the City's website
ww w_mt „r n oLgfis
g gQy
or can be
obtained at
City Hall
during
normal business hours.
• Plans/calculation/reports
prepared by state licensed architects or professional
engineers
must
be stamped
and signed
by the
design
professional.
FORM C LABuilding New Folder 2010\OONE & x-ferred to L-Building-New drivelForm C 2014.docx Updated: 1/17/2014
FIELD NOTES:
JOB COMPLETED By�:
Site info taken by,
u—
Dee dlin
DATE:-