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DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
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PERMIT APPLICATION
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121 5rh Avenue N, Edmonds, WA 98020
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Phone 425.771.0220 !k 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 #:
5"�"
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT. Phone° Fax:
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Address (Street„ City, State, Z�!_
E-Mail Address:
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PROPERTY OWNER, Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
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LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E-Maul Address:
CONTRACTOR:* Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
WA State License #/Exp. Date:
*Contractor roust 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 t Business License #/Exp. Date:
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK: -� ... �... 9_ LD 4k, _
t.1 ...... ......... __ W..__ . ...... ....
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.
PrinI Name: _...._-- ��' .. .....�_-.. _-. Owner ❑ Agent/Other (specify):��
Dates( �.. ?.-..-
FO M C LABuilding New Folder 2010vDONE c& x-fenred to L-Building-New drivevForm C 2014.docx Updated: 1/17/2014
MECHANICAL
Equipment Type Appliance/Equipment Information (new and relocated) Total #
Furnace I Gas # Elec#_Other: #,121LBTUs: <100k ......... >100k Location(s).,,..,,.,, , u, I
Air Handler / VAV
Gas #_Elec #_Other:.._..—v,,__,.— # CFM: <10k_ >10k_ Location(s)
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Gas #Elec #_Other:.,-__ #_.................. BTUs: ..............................<100k, .................................... 100k-500k, ......... ........_500k-1Mil
Roof Top Unit
HP: <3, 3-15, 15-30 Location(s)...................... ..w........ ...-....................�......—-_.......-...................m....... ......_...�..........�..��
(circle selected)
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Hydronic Heating
Gas #Elec #_In -Floor _Wall Radiant_ Boiler BTUs: Loealit,tn __. u_u.,,
Exhaust Fans (single
Bath # # .......Laundry # i:ltltea':'_._—.�.. ... __,.-.... �.�-.�...,, e � ... �..
duct)
.........Kitchen
Fireplace I Gas #_Elec #_Other: # Location(s)
Dryer Duct
FORM C L:\Building New Folder 201 HONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014