20161006105618.pdfS.
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Asa. 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): Parcel #:
�3 [5 -7 7 A\/ 6 vll
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT: Phone: Fax:
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Addrresss (Street CitSl"5 ); Wail Address-, f 5C_f,
, 1� %& 'a'M./AL�`'G'U
PROPERTY OWNER: Phone: Fax:
Address (Street, City, State, Zip): , w E-Mail Address:
_715 -7Avg
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
CONTRACTOR:* Phone: Fax:
F, avr�C ?� LL 1L/24' S%-y &
Address (Street, City, Stale, Zip): E-Mail Address:
WA State License #I1,Exp. Date.
*Contractor must have a valid City of Edmonds business license prior to doing work tV I A- 96 q-7 / �
in the City. Contact the City Clerk's Office at 425.775.2525 City Business License li/Ex . Date:
Z
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK:� �S
..........� �� _ . _.. �.............
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: _,. _,. Owner;ZAgent/Other ❑ (specify):
Signature; __...._ ' Date: ��O
FORM C LABuilding New Folder 2010\DONE & x-ferred to LrBuilding-New drive\Form C 2014.doex Updated: 1/17/2014