20161123115435.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 9 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADD SS (zStu�cet, S�Mite #, CityState, Zip): Parcel #:
0 el)` �/Y �0��✓l.�o% gc
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT: 1/ F J` fQ V t42 V AC Phone: �� 00 V Fax:
1 j�
Addressr ( Street, City, State, Zi �� r� E-Mail Address,
1 4eD
PROPERTY OWNER: pi A- n * 1 E El-
o j Phone: Fax;
Address (Street, City, State, Zip):' J ! E-Mail Address:
116,
LENDING AGENCY: I Phone: Fax:
Address (Street, City, State, Zip):
CONTRACTOR:* E r t lk
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
DETAIL THE SCOPE OF WORK:
All
MECHANICAL I I TANK
E-Mail Address;
Phone:, Fax:
�z
-Mail Add 41e c
WA state, ,��e �tlIxl i�i1le: 0
City Btp�i License #llixp. Date:
A' - ozza,2
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: ......��_-..� .....'.. ..... .............� �_.N�._ �� ...�.�.. Owner ❑ Agent/Other (specify) _... ....._,,, _.....___—..
Signature: .... _ _... ....w ... M_.-.. Date ....,w... ...._® •.. ....
FORM C L:\Building New Folder 201MONE & x-ferred to L-Buildirig-New drive\Form C 2014.docx Updated: 1/17/2014
PLUMBING
Fixture Type (new and relocated)
FIXTURE COUNT �
Total # Fixture Type (new and relocated)
I
Total #
Water Closet (Toilet)
�w-
Pressure Reduction Valve/Pressure Regulator
Sink kitchen, laundry, lavatory, bar, eye
( y y e wash, etc.)
_.... -
Water Service Line
Tub/Shower
----------------
Drinking Fountain
_— ..........
Dishwasher
Clothes Washer
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes ❑ No ❑
Hydronic Heat i mm uW
n: Floor ❑ Wall ❑
-
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
Equipment Type Appliance/Equipment Information (new and relocated) Total #
Furnace Gas #_Elec # Other: # BTUs: <100k_ >100k Location(s)__m
Air Handler / VAV
Gas #_Elec #_OIhe�t # CFM: <10k_ >10k_ Location(s)..... „mm -
(circle selected)
.....,,,,
AC / Compressor /
Boiler/ Heat Pump /
Gas #_Elec #.................. Other: .......................... .......... ..................... #................... ... BTUs: ................................... <100k,............................... _.100k-500k,.................. ............... 500k-1Mil
Roof Top Unit
HP: <3, 3-159 15-30 Location(s)__., .....................� —--..................... ............................�....... ,�..
(circle selected)
Hydronic Heating
Gas #m„,m„, Elec #...._- _In -Floor _Wall Radiant ........ Boiler BTUs: ............... Location.-
Exhaust Fans (single
Bath a iKitchen #_Laundry # ........................ — _.._ ..# .,.... .
duct)
........................
Fireplace I Gas #_Elec #_Other: #_ Location(s)
Dryer Duct
Appliance Type Appliance/Equipment Information (new and relocated) Total #
AC Unit
BTUs: ....... ...... ....... .�.�.......................... .....__.._
Location(s):-_._..---., r_.................................,,,..._......... __.._-.............................W.
Furnace
BTUs: ..
Location(s):—,,.,,,,-
Water Heater . „.
......
, BTUs:. .-.-...�—
Location(s)�...... , _._ _----_ ...... ..
Boiler
BTUs..
Location(s):.._.n .. _ �..... _..... .... ,,_
Other ...__.._._... _......_.
BTUs: _ _ ......
Location(s): w.__.. ._..... .. —_ µ
Fireplace/Insert
� ...
BTUs:. _- . �....���—
. Locations):--.w.......-
- ..-- � � m. ._w
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C, L:\Building New Folder 2010\DONE & x-fened to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014