20170112091735.pdft DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
, PERMIT APPLICATION
121 51h Avenue N, Edmonds, WA 98020
t n �okl Phone 425.771.0220 ft 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:
_rN F (LA S LLC 9Zsr4p-/g9
Address (Street, City, State, Zip):
E-Mail ,ddr ss.
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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-Mail Address:
CONTRACTOR:* Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
4 to .STC-VJA T Il A 963 9 o
WA State License #/Exp. Date:
*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 City Business License O i[Fx ). Date:
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK:... _.... - /`.... ...../..., / /y........ ......y.. ........
RL' �.UC�4.-T"�.V,�'V
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 !� �• Owner;Agent/Other ❑ (specify):
Signature: Dater
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FORM C L:\Building New Folder 2010\DONE & x-ferred to 1 Building -New drive\Form C 2014.docx Updated: 1/17/2014