20161215153926.pdf�' rr DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 It 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 #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT:
Phone: Fax:
Address (Street, Ci State, ):
E-Mail Address:
, S
PROPERTY OWNER:
Phone: Fax:
11
v� �n
N - 77 - )o �
Address Street, Cit State, Zip)-
1LlQt c� 2 L
E-Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRA( OR * M .I
r �w l^
Phone: Fax:
y25 — 7_
Address reet, ty, State, Zip):
`°°7
E-Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
" 13 ° 19,30
in the City. Contact the City Clerk's Office at 425.775.2525
Cityy Business License #/Exp. Date:
PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK ��.::�.....� a� �.
�°-....:.. ... .
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.
i Print Name: �nnnnn°� �`�P Owner ❑ Agent/Other I�- 7
� (specify):
i later .,,
Date: t
FORM C LABuilding New Folder 2010\130NE & x-ferred to L Building -New driveTorm C 2014.docx Updated: 1/17/2014
PLI)MBING FIXTURE COUNT
Fixture Type (new and relocated) Total # Fixture Type (new and relocated) Total #
Water Closet (Toilet) Pressure Reduction Valve/Pressure Regulator
........www_ M .... ...........
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.) Water Service Line
Tub/Shower Drinking Fountain �� �....-IT ���� ............
Dishwasher Clothes Washer
Hose Bib Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes ❑ No ❑ Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink Other:
Refrigerator water supply (for water/ice dispenser) Other:
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated) Total #
Furnace
Gas #
Elec #m_..Other':.__.__..___M._.
# BTUs: <100k— >100k
_ Location(s)
Air Handler / VAV
Gas #,_mm
#,_
#,,,,,,J__ CFM: <10k_ >10k
Location(s)_
(circle selected)
_Elec
,,,,_Outer:
IT__
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)
(circle selected)
Hydronic Heating
Gas #„,,,,,,_wElec
#_-wwww-In-Floor
Wall Radiant— Boiler BTUs:
Location,_.... —.
Exhaust Fans (single
Bath #
Kitchen #_Laundry #
#„
duct)
_Other:
Fireplace
Gas #—Elec
#—Other:
# Location(s),_, ..............
,__ _ _w__wwww_ wwwwwwwwwww
L=1L—
Appliance
Dryer Duct
Type Appliance/Equipment Information (new and relocated) Total #
AC Unit BTUs:. Location(s):
Furnace BTUs:.. _ �......... Location(s):,_
Water Heater BTUs: , Location(s):_..... _ _....
Boiler BTUs: Location(s):_, ............... ............ ..............._ .....__..
.......
Other: BTUs: Location(s): ...........
Fireplace/Insert BTUs: ............ Location(s):
Stove/Range/Oven
Dryer
__ .... .. .................. .. .. .v................................ ........... .__Wv_._..W_
Outdoor BBQ
TOTAL OUTLETS
FORM C LABuilding New Folder 2010\130NE & x-ferred to LrBuilding-New drive\Form C 2014.docx Updated: 1/17/2014
FORM C LABuilding New Folder 2010\130NE & x-ferred to LrBuilding-New drive\Form C 2014.docx Updated: 1/17/2014