20160908111604.pdfT DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 !k 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 sT' PLALE- V-1 1=�,�••a^jDS, wA 8oz0
doSZS I
00 00
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT: V t.1 k VE*S A,_ AfNic Ajt0tS . t NL ,
Phone: Fax:
206.74-Z •77-op Zob•76Z•7-TS7
Address (Street, City, State, Zip):
SFA—fTt-E
E-Mail Address:
1 So ca r l*�� S r. wA 78/ O ¢j
NA-1— Cw rw% Ofst-00
PROPERTY OWNER: r—ATIL("A' f_,tLEF_NI PF-A l- "rA-TES
Phone: Fax:
7,o�•t6L•��17�
Address (Street, City, State, Zip):
E-Mail Address:
p
70l Tr" A ,,6 - STD LOQ • EA-TTLE WA / SO ZO
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* VA)jV15" A,._ Aot,(c ATOP-S A (N C- .
Phone: Fax:
76'L• 7S•Oc0 1A6 •7C2.77r7
Address (Street, City, State, Zip):
E-Mail Address:
S/.5— 5. SR-1 ftA,4 ST_ L- nr-rrLf A g6 r 016tna
�_ .y. A t..61zz, .cow,%—
WA State License #/E'Xp. Date: 12. 31
*Contractor must have a valid City of Edmonds business license prior to doing work
7 "1487 .41
in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
NJz—— 017-00S
PLUMBING MECHANICAL TANK
DEMOLITION Ll
DETAIL THE SCOPE OF WORK: w, �E dt" �^" `SS (0 100 41.' ej V rXt�E k-61"V ND
t ts e N T 1 k .... .. t A ,J -
Inl N-Cc $
�—oNM nlL .
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: l't' / " t" Owner ❑ Agent/Other (specify):
Signature: Date: q
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
Type of Gas/Air/Vacuum System (new and relocated) Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
Helium
Medical — Surgical Vacuum
Other:
TOTAL OUTLETS
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
7P�Iiace
..........
_ _. — ....... _ —..... ....Fill Material t-d A M Fill in Place ❑ Fill Material
Removal Removal
._❑
.�..... ...... ...� _..._... _...
Number of Gallons: 3 Number of Gallons:
.........
ITIT.ITIT _.
Critica1 AyRe.... q ❑ ❑ Waiver........
Areas Determination: Stud Required Conditional Watver
Type of structure to be demolished (e.g. house, shed, garage, etc.):
Floor area of structure to be demolished: sq. ft.
_._..._. __............. _ .....
Critical Areas Determination: Study RequiredEl Conditional Waiver ❑ Waiver El
PSCAA Case No. J, AHERA Survey done? (required) ❑
Additional comments:
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
__L " -� n
`vD ) sN�v�l� C
44