20170113092920.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
" PERMIT APPLICATION
121 50` Avenue N, Edmonds, WA 98020
St Phone 425.771.0220 2 Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Soitetf,Cit t te, Zip):
Parcel #:
.
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT: w a
Phone: l Fax:
Address (Street, City, Stale, Z ..
E-Marl Address:
.i
.- �.
Phone: Fax:
10
PROPERTY OWNER:
Address( tT et Cit , State Z t )° '
LStj
E-Mail Address:
EN G AGENCY:
Phone:
Fax:
ZN(Street, City, State, Zip):.
E-Mail Address:
CONTRACTOR:*
Phone: Fax:
Ad ess (Street, City, State, Zip):
E-Mail Address:
Wtk State License ./Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work
P t
in the City. Contact the City Clerk's Office at 425.775.2525
'
City I 'usi 1 ss Licetls 71E,Xp. Date:OK
t
PLUMBING MECHANICAL TANK
DEMOLITION
DETAIL THE SCOPE OF WORK: On
464. �A
I declare under penalty of perjury laws that the infartnati n I have provided on this formlapplicatian is true, correct and complete,
axtd that I am the prt)per t� artpner or dtt4tx autltari c(I a it oaf the property owner to submit
a pertnit application to the City ql`
Edmonds.
Print Nalne: _ -!� ....... Owner � Agent/Other El (specify)« .� __ww
Signature: Date:.
IL
FORM C L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014
PLUMBING O
Fixture Type (new and relocated) Total # Fixture Type (new and relocated) Total #
Water Closet (Toilet) Pressure Reduction Valve/Pressure Regulator
Sink (kitchen, laundry, lavatory, bar, eye 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 in: Floor ❑ Wall ❑
Floor Drain/Floor Sink Other:
-Refrigerator water supply (for water/ice dispenser) Other:
Equipment Type
MECHANICAL
Applianc Xquipme:nt Information (new and relocated)
Total #
Furnace
Gas #_Elec
#_Other:
#_ BTUs: <100k >IOOk
Location(s)
Air Handler / VAV
Gas #_Elec
#_Other:
# CFM: <10k >10k
Location(s)
(circle selected)
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 #
#�
duct)
_Other:
Fireplace
Gas #
Elec #_Other:
# Location(s)
Dryer Duct
Appliance Type
AC Unit
Furnace
. . ............ . ...... .......... ...
Appliance/Equipment Information (new and relocated)
BTUs: Location(s):
BTUs: Location(s):
.......
Total #
Water Heater
BTUs: Location(s):,
Boiler
BTUs: Location(s):
Other:
BTUs: Location(s):
Fireplace/Insert
BTUs: Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C L:Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014