22708 78 AVE W-APP.pdf2LO» -I Sa%
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5°i Avenue N, Edmonds, WA 98020
•� t, I ys Phone 425.771.022011 Fax 425.771,0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): �iM dN D S, WA Parcel #:
Z2768 78� Av6_ vv 9802e 40527800oo23o0
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No V
APPLICANT: V 1..�CI�TdiLS, tJC.. Phone: Fax:
UN�S� PrPP 206'74Z-• 7Sa0 27e6.7.61.775
Address (Street, City, State, Zip): E-Mail Address:
5'1!r S. S1,jrk+ " S-F. S ,-ram wA R81oQ� uq,;_ l—+M al.00. Car
PROPER Y OWNER: Phone: Fax:
< <-E-- e—D 1 2 ab • 71 `{ • D 3 6 7
fit, City, State, Zip): �pMO^�S� t E-M iI Address:
Address (Scree r
" 7 'a' !� 2 I In w mar vtrd fs 1 G�[wSf.
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
CONTRACTOR:* Phone: Fax:
UN\ve"e_c_ 4t colt- . 20 762• 7nO z •76Z• 77
Address (Street, City, State, Zip), � E-Mail Address:
WA State License 11/Exp� Dale:
*Contractor must have a valid City of Edmonds business license prior to doing work O • / Z
in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date -
At $ t'Z1 l�o
PLUMBING MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK: FMD ✓iFI— _� W��-.... ._ ..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.
Print Name: _ (' Owner ❑ Agent/Other � (specify): CDNT(2ACTd 2 -
w
Signature: Date:
�..
t' _.
� 1
FORM C LABuilding New Folder 2010\DONE & r-Ferred to L-Building-New drive\Form C 2014.doex Updated: 1/17/2014
Type of Gas/AirNacuum System (new and relocated) Total#
Oxygen
Nitrous Oxide
Medical Air
Carbon Dioxide
......
Helium
... �_.�.. _ �.... .....m.m.
Medical —Surgical Vacuum
... ............
Other:............A
TOTAL OUTLETS
TANK #1 TANK #2
Method of Abandonment Method of Abandonment
Fill in Place ❑ Fill Material Fill in Place Fill Material
Removal ..................
. ._� �}{,�M EN '"Removal al ❑ e ..... Number of Gallons: 300 _ Number of Gallons:
-. uw
Critical Areas Determination: Study Required Conditional ��.
Waiver Waiver
Type of structure to be demolished (e.g. house, shed, garage, etc.):
Floor area of structure to be demolished: sq. ft.
Critical Areas Determination: Stud Required Conditional � ___._._W..... _........���.....mm
y ey e Q nal Waiver ❑ Waiver ❑
.................... ._... _ .. .........._�
PSCAA Case No w._
,AHERA Survey done? (required) Elm....._ _ ... ... �..... .......� _.�. __...�� _ _._..
Additional comments: _
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated; 1/17/2014
S NarfrT3VVIq - VVN ,
-5�AV , 9Z
C7)_Zoy6 dry 'sc+r°�•a3