20160830114853.pdf`BbDaoc�0-112Z
V
st IIA4
City of Edmonds
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
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT. Yes Nwoa
Associated Permit #:
State,
Address (Street, CtC, State, Zip):
LENDING AGENCY:
Address (Street, City, State, Zip):
C"a'll'VT1tAt"I^M?-*.,I I—,
ty, Stay , Zilx):;
*Contractor must have a valid City of Edmonds business license
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING
DETAIL THE SCOPE OF WORK:
MECHANICAL
Phone:
Phone:
Fax:
E-Mail Address:
C... WA I tlt. 're`ense Pl xp.�<1ter:
dotiq work j� .
City 1lttsine, s License #/Exp. Date:
i
TANK DEMOLITION
rd
Ulm
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.
w,
Print etac. b„
"".a ,,� �;� ' -"Owner ❑ A etaGlC
a
Si,8natt �
Date• . mw� .�
FORM C L:1Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
FORM C; L:Wuilding New Folder 20101DONE & x-(erred to L-Building-New driveTorm C 2014.docx Updated: 1/1712014