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DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
Abf PERMIT APPLICATION
hs t Rr111 121 5"' Avenue N, Edmonds, WA 98020
Phone 425.771.0220 !& 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 #
H724 �/wl -S � 2
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No E
APPLICANT: r.) L RIA%
Address (Street, Ci, Sta e, Zip):
�l
PROPERTY OWNER: AP
Address (Street, City, State, Zip):
LENDING AGENCY:
Address (Street, City, State, Zip):
CONTRACTOR:*
Address (Street, City, State, Zip)
*Contractor must have a valid City of Edmonds business license prior to doing work
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING I I MECHANICAL II TANK
Phone: Fax:
7aq' g ,
E- ail Address: .___
A iAl 0- dt-u1ruGt`v,.G-I
Phone: 11 Fax:
E-Mail Address:
Phone: Fax:
E-Mail Address:
Phone: Fax:
E-Mail Address:
WA State License#/Exp. Date:
City Business License #/Exp. Date:
DEMOLITION
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�r.. .._.. _... OwnerAgent/Other ❑ (specify):
Signature: ---.. Date
...... .s ..�.. �._.. _.
�.,.�.....�.��� !/ 2//d..� .. ....._..... ...
FORM C L:\Building New Folder 2010\DONE & x-Ferred to L-Building-New drive\Fonn C 2014.docx Updated: 1/17/2014
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #
Elec #_Other:
# BTUs: <100k >100k
_ L(Watiou(s),.,,.--„
Air Handler / VAV
Gas #
Elec #Other:
#CFM: <lOk_ >lOk
Location(s)
(circle selected)
w
.—
,.
AC /Compressor /
Boiler / Heat Pump /
Gas #-------Elec
#_Other:.
,,------- # ----- --. BTUs- ------------<100k, --------
100k-500k, ------------_500k-lMil
Roof Top Unit
HP:
,<3,
3-15, .,_ 15-30 Location(s)
(circle selected)
Hydronic Heating
Gas #Elec
#_In
-Floor _Wall Radiant_ Boiler BTUs:
Location
Exhaust Fans (single
Bath #....Kitchen
#_Laundry # .tltlta a _ww
_��..
duct)
Fireplace
Gas #,........
Elec I) ..,..-Otha
r....___,_"'_"'__#___.._ Location(s)_. ....y
_..� ..._— . ..
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs ....
�...., Location(s):-......... . _ _ .._ ....... _,------- �....n......
Furnace
BTUs:
_r _ Location(s): A._.__ _r_-u.�...
. .....
... . ..
. ...
Water Heater
BTUs: -----------
LocationO,_......... __. �.. ...... .. .....
Boiler
BTUs:....
m Location(s)w. ._.-_'__'_ . ..�-.....
Other: - ...........
.....
BTUs:
�....._.... ,..._ . Location(s)=.-
Fireplace/Insert
BTUs:
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\DONE & x-f'erred to L-Building-New driveTbrin C 2014.docx Updated: 1/17/2014
EXEMPTION FROM CONTRACTOR
REGISTRATION VERIFICATION
FORMI)
The undersigned property owner or authorized person as described below, has applied for a
building permit from the City of Edmonds and claims that he/she/it is exempt from providing
contractor registration in accordance with the provisions of RCW 18.27. The property owner or
authorized person, by their signature below, hereby verifies to the City of Edmonds that'
❑ Value of work under $500.00. The aggregate contract price of labor and materials and all
other items required for the project is less than $500.00 and is not part of a larger operation
to be undertaken on the property, This exemption does not apply to a person who advertises
or puts out any sign or card or other device which aught indicate to the public that lie/she. is
a contractor, or that he/she is qualified to engage in the business of contractor. RCW
1 .27.090(9).
6 Owner who contracts for a project. A property owner contracting with registered
contractors for the project, and who him/herself is not performing any activity of a
contractor for the purpose of leasing or selling improved property that he/she has owned for
less than twelve months. RCW 18.27.090(11).
❑ Work performed personally on own.property. Anyone personally working on property
he/she owns, or at which he/she resides, as long as the property owner, or resident, does not
perforn any activity of a contractor on his/her property for the purpose of selling,
demolishing, or leasing the property. RCW 18.27.090(12).
❑ Use of own employees. Property owner using him/herself or his/her own employees to
perform maintenance, repair, and. alteration work in or upon his/her own property. RCW
18.27.090(13).
❑ Licensed Architect, engineer, electrician or plunal�er. All work performed under this
permit will be perfoin ed by an architect, civil or professional engineer, certified electrician
r certified plumber operating within the scope of his/her certification. RCW 18.72.090(14).
❑ Other. Specify which provision of RCW 18.27.090 applies:
THE UNDERSIGNED PROPERTY OWNER OR AUTHORIZED PERSON HEREBY VERIFIES
THAT ALL INFORMATION PROVIDED. ON THIS FORM IS TRUE AND ACCURATE TO THE
BEST OF HIS OR HER KNOWLEDGE AND ACKNOWLEDGES THAT IF ANY OF THE
INFORMATION PROVIDED ON THIS FORM IS FALSE HE OR SHE UNDERSTANDS THAT THE
BUILDING PERMIT WILL BE IMMEDIATELY REVOKED AND ALL FEES PAID FORFEITED.
DATED this day of '-` �, 20�.
PROPERTY OWNER/AUTHORIZED
PERSQ
Signature
IJAM�- C. QugiaJ
Print Name
WITNESS_
S r1 t'ure .__.
Print Name
LATEMP\BUILDING\HANDOUTS REVISED IN 2009\PREVIOUS HANDOUTS\FORMS\CONTRACTOR EXEMPTION FORM
D.DOCREVISED 7/07