20160718122133.pdfOV Lara
DEVELOPMENT SERVICES
PLUMBING & MECHANICAL, TANK & DEMOLITION
PERMIT APPLICATION
I; 121 5`h Avenue N, Edmonds, WA 98020
Irj Phone 425.771.0220 4 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 #:
21916 78th Pl W
01129500000200
APPLICANT:
pphh Fax;
Bob's Heating and A/C
80o�e 840-3346
Ad(Street, ty, State, Zip):
E -Mail Address:
14148 NE 190th ST Woodinville Wa 98072
lhonevcutt@bobsheatincl.com
PROPERTY OWNER:
Phone: Fax:
Melody Fan
206-295-2970
Address (Street, City, State, Zip):
E -Mail Address:
21916 78th Pl W Edmonds Wa 98026
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip).
E -Mail Address:
CONT�tt;1CTOR:*
Bopp s Heating and A/C
Ph n Fax:
0-840-3346
Address (Street, City, State, Zip):
License #/Exp. Date:
14148 NE 190th ST Woodinville Wa 98072
BOBSHHA853NO
*Contractor must have a valid City of l^xlrrnonds ba siness license prior to doing work in the
Cit Business License #/Exp. Date„
YNR -014338
City. Contact the City Clerk'Office at 425.775.2525
CXPLUMBING ❑ MECHANICAL ❑ TANK CI DEMOLITION
.....................
I declare underpenalty 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: Lucinda Honey utt ❑ Owner
CXA ent/Other (specify): contractor
g P Y
Signature: Date:
7/14/16
FORM C C:\Documents and Settings\bjorback\Desktop\Fomi C.doc
8
Updated: 10/2010
TANK #1 TANK #2
Number of Gallons Number of Gatlnnc_
Method of Abandonment Method
m
....�.. mm of Abandonment
...... � Fill in Pl...._. �..��� ...�_ ........� � _�._..._ ...... �_......
ace Fill Material,_µ_.
Fill in Place Fill Material...m m
Pump, Rinse & Cap Pump, Rinse & Cap
..........
_..........
Removal Removal
Critical Areas Determin n IT
�..... ation: ❑Study Required ❑Cnditional oWaiver El Waiver
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
Furnace
#_Gas
#_Elec
#_Other:
BTUs: <100k_>100k_
Location
Air Handler/AC/VAV
#_Gas
#_Elec
#_Other:
CFM: <100k_>100k_
Location
Boiler/Compressor/
#_Gas
#_Elec
#_Other:
BTUs: <100k,
100k -500k, 500WINIll
Heat Pump/Roof Top
HP:
<3,
3-15,
15-30
Location
Unit
Hydronic Heating
#Gas
#_Elec
—in
-Floor, _Wall
Radiant, Boiler BTUs:
Location
Exhaust Fans (single
Location: #_Bath
#_Kitchen
#_Laundry # _Other,
duct)
Fireplace
#_Gas
#_Elec
#_Other:
Locailon
....
Other
FORM C C:\Documents and Settings\bjorback\Desktop\Form C.doc Updated: 10/2010
Number Fixture Type Number Fixture Type
Water Closet (Toilet) Refrigerator water supply (for water/ice dispenser)
Sink... .
(kitchen, laundry, lavatory, bar, eye wash, etc.) Water Service Line
Tub/Shower Drinking Fountain
Dishwasher .__..... _..._ ......
Bidet/Urinal
.ITIT.IT.IT..IT..IT Hose B�b_IT... Pre. _._..�e_ ___
__ Pressure Reduction Valve/Pressure Regulator
1 Water Heater Tankless? Yes_ No x Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
.......__ ......
Expansion Tank.. rmm ._. _..� _.
o Water Heater Hydronic Heat in: Floor Wall_
w_ �. _........_ _...... �..
Floor Drain/Floor Sink Other:
Clothes Washer Other:
MEDICAL GAS, AIR, VACUUM
FORM C C:\Documents and Settings\bjorback\Desktop\Form C.doc Updated: 10/2010