20161014135443.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 Fax 425.771.0221
City of Edmonds m
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel#: 0000D 3-c>O
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes% No ❑ &V z 0/& &
APPLICANT: ' Phone: Fax:
960065,dIV, 1) ,C,+,, v
Address (Street, City, State, Zip):
i E-Mail Add s: �I )
7o��� U G Nip G11A
PROPERTY OWNER: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
CONTRACTOR:* l Phone: Fax:
Addres recC, City, State, Zip : p E-Mail Address:
WA State #
Contractor must have a valid City of Edmonds business license prior to doing work 2 Date:
'cen�,� /i
in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK:
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 0 Agent/Other [I] (specify):
Signature: .. rv' _ Date:
FORM C LABuilding New Folder 201000NE & x-ferred to LrBuilding-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
Fill in Place ❑ Fill Material Fill in Place ❑ Fill Material
Removal ❑ Removal
Number of Gallons: Number of Gallons:
Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver El
Type of structure to be demolished (e.g. house, shed, garage, etc.):_IT,,,,IT,ITITITITIT,IT,,,,............................ — _...
_w._w.-._.... __............................................................................................................................................................................................................._...... ................... ...................
Floor area of structure to be demolished:, sq. ft.
Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑
PSCAA Case No. AHERA Survey done? (required) ❑
Additional comments:
FORM C LABuilding New Folder 201000NE & x-ferred to L Building -New drive\Form C 2014.doex Updated: 1/17/2014