20161019115011.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
r PERMIT APPLICATION
1215 1h Avenue N, Edmonds, WA 98020
est 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 #:
04
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT. A/"
Phone: Fax:
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Address (Street, City, te, Zip):
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PROPERTY OWNER:
Phone: Fax:
20(PrjL3 34A0
Address (Street, City, State, Zip):
E -Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR• r
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Phone:
Fax:
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Address (S t, City, State, Zip):
E -Mail Address:
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WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
City Business License #/Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK:
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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 ✓ `+'^ p Owner Agent/Other ❑ (specify):
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Signature: + Date:
FORM C L:\Building New Folder 2010\130NE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014
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Fixture Type (new and relocated)
Total #
FIXTURE COUNT
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
-------- _
Furnace
Pressure Reduction Valve/Pressure Regulator
_ ......... ......---------.
#
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Location(s)w_,_
Water Service Line
Air Handler / VAV
(circle selected)
Tub/Shower
Elec #
Drinking Fountain
_
Location(s)
Dishwasher
AC / Compressor /
..... .........
Clothes Washer
BTUs: ,,,mmmITITIT__ _,,,,,,,,,,,, Location(s):..—..._..�.......---------. ........
....____
Hose Bib
Stove/Range/Oven
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Boiler / Heat Pump /
Water Heater Tankless? Yes ❑ NoE]
Elec #_„Other:_,._.
Hydronic Heat in: Floor ❑ Wall ❑
100k -500k, 500k -1M11
Floor Drain/Floor Sink
Roof Top Unit
Other:
.........<3,
Refrigerator water supply (for water/ice dispenser)
Other:
(circle selected)
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
................................
...........
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #_E(ec
#
�Ctlaer:,�IT # .......- BTUs: <100k >100k--
Location(s)w_,_
BTUs: _ Location(s):
Air Handler / VAV
(circle selected)
Gas #
Elec #
Otiter #_CFM: <10k_ >10k
Location(s)
BTUs: ........_--..�. Location(s):......... .......... _---
AC / Compressor /
Fire lace/Insert
p
BTUs: ,,,mmmITITIT__ _,,,,,,,,,,,, Location(s):..—..._..�.......---------. ........
....____
Stove/Range/Oven
Boiler / Heat Pump /
Gas #—
Elec #_„Other:_,._.
# BTUs: <100k,
100k -500k, 500k -1M11
---.-..------ ._
Roof Top Unit
HP:
.........<3,
3-15, 15-30 Location s
() re.
(circle selected)
__,_............ ._ µµµWWW
Hydronic Heating
Gas #Elec
#_In
-Floor _Wall Radiant_, Boiler BTUs: ...............
., Location
Exhaust Fans (single
Bath #_Kitchen
# Laundry #
#
duct)
_Other:, _-- _-
_,,,,,,
Fireplace
Gas #,—Elec
#
00ter: #_ Location(s),
........
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: Location(s):__ ................ .-.
Furnace
BTUs: — ........ ........ Location(s): -- ......
Water Heater
BTUs: _ Location(s):
Boiler
BTUs: Locattitan() _..._
Other: __ ... ----
BTUs: ........_--..�. Location(s):......... .......... _---
Fire lace/Insert
p
BTUs: ,,,mmmITITIT__ _,,,,,,,,,,,, Location(s):..—..._..�.......---------. ........
....____
Stove/Range/Oven
Dryer
.. . .................. .... ..
Outdoor BBQ
---.-..------ ._
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\130NE & x-ferred to L Building -New drive\Form C 2014.docx Updated: 1/17/2014