BLD20161465.pdf12
V,
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
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 #:
%6 2• f 2 3 91'I P
04 9 P& z&
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No
APPLICANT:
Phone:
Fax:
�L2t-V(—,7;r
Address (Street, City, State, Zip):
1)d 1 429, P� Svc eA-V R-V%d 5
E -Mail Address:
y 1,y&j AjVjv y VPwA W1 *40. ce
PROPERTY OWNER:
Phone:
Fax:
Address (Street, City, State, Zip);
E -Mail Address:
LENDIN AGENCY:
Phone:
Fax:
ess (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:* O' `� �
` v
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license
prior to doing work
City Business License #/Exp. Date:
in the City. Contact the City Clerk's Office at 425.775.2525
PLUMBING MECHANICAL I I TANKI DEMOLITION
DETAIL THE SCOPE OF WORK:
------------
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: N� lJl �� M
Owner ® Agent/Other ❑ (specify):
Signature:
Date:r� /w
FORM C LABuilding New Folder 201000NE & x-ferred to L -Building -New driveTorm C 2014.docx Updated: 1/17/2014
PLUMBING
Fixture Type (new and relocated)
[Sink
Total #
FIXTURF COUNT
Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
_W__....... .._�.
Furnace
Pressure Reduction Valve/Pressure Regulator
#t')klter;
(kitchen, laundry, lavatory, bar, eye wash, etc.)
._.w. .....
Water Service Line
._
1W ...........................
Tub/Shower
Gas #_Elec
Drinking Fountain
Other ___ ...... ......... ..... —
Dishwasher
Location(s)
Clothes Washer
(circle selected)
Hose Bib
Stove/Range/Oven
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes ❑ No ❑
Hydronic Heat in: Floor ❑ Wall El
Outdoor BBQ
Floor Drain/Floor Sink
Other:
TOTAL OUTLETS
Refrigerator water supply (for water/ice dispenser)
Boiler / Heat Pump /
Other:
Elec #_,Other;_
Equipment Type
Appliance/Equipment Information (new and relocated)
Total #
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #_Elec
#t')klter;
_
#..... ---. BTUs: <100k.— >100k,_
Location(s)
Air Handler / VAV
Gas #_Elec
#_Other:
Other ___ ...... ......... ..... —
#_CFM: <10k >10k_
Location(s)
Fireplace/Insert
(circle selected)
Stove/Range/Oven
Dryer
AC / Compressor /
Outdoor BBQ
TOTAL OUTLETS
Boiler / Heat Pump /
Gas #
Elec #_,Other;_
_--------------...m
# BTUs: <100k,
100k -500k, 500k-1Mil
Roof Top Unit
HP:
<3,-3-15
. ............................. 15-30
Location(s)
(circle selected)
Hydronic Heating
Gas # ......,Elec
#,
In-FloorWall Radiant_ Boiler BTUs:,
I ocatiou,_ITITITITITITITITITITITITITIT._IT...........
Exhaust Fans (single
Bath #
Kitchen #_Laundry #Othcr:�_---_
duct)
www ,_,_,___--------------�#�
Fireplace
Gas #_Elec
#_Other:
....................................._______.
# Location(s),
.. ........,
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: , Location(s):_.,,_�mmmm
Furnace
BTUs: Location(s): _-
Water Heater
BTUs:...-..... Location(s): w.w.__ ........................................_--------.----.
Boiler
BTUs: w Lticatiuct(s): .w___- .......
Other ___ ...... ......... ..... —
BTUs: Locatiou(s). ............--------....----....----._...--- ..
Fireplace/Insert
BTUs: Location($) .www_..,..,..
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
FORM C L:\Building New Folder 2010\130NE & x-ferred to L -Building -New drive\Form C 2014.doex Updated: 1/17/2014
EXEMPTION FROM CONTRACTOR
REGISTRATION VERIFICATION
FORM D
The undersigned property owner or authorized person as described below, has applied for a
building permit from the City of Edmonds and claims that he/she/it is exempt from providing
contractor registration in accordance with the provisions of RCW 18.27. The property owner or
authorized person, by their signature below, hereby verifies to the City of Edmonds that:
Value of work under $500.00. The aggregate contract price of labor and materials and all
other items required for the project is less than $500.00 and is not part of a larger operation
to be undertaken on the property. This exemption does not apply to a person who advertises
or puts out any sign or card or other device which might indicate to the public that he/she is
a contractor, or that he/she is qualified to engage in the business of contractor. RCW
18.27.090(9).
Owner who contracts for a project. A property owner contracting with registered
contractors for the project, and who him/herself is not performing any activity of a
contractor for the purpose of leasing or selling improved property that he/she has owned for
less than twelve months. RCW 18.27.090(11).
Work performed personally on own property. Anyone personally working on property
he/she owns, or at which he/she resides, as long as the property owner, or resident, does not
perform any activity of a contractor on his/her property for the purpose of selling,
demolishing, or leasing the property. RCW 18.27.090(12).
Use of own employees. Property owner using him/herself or his/her own employees to
perform maintenance, repair, and alteration work in or upon his/her own property. RCW
18.27.090(13).
Licensed Architect, engineer, electrician or plumber. All work performed under this
permit will be performed by an architect, civil or professional engineer, certified electrician
or certified plumber operating within the scope of his/her certification. RCW 18.72.090(14).
Other. Specify which provision of RCW 18.27.090 applies: �.n..,.,
THE UNDERSIGNED PROPERTY OWNER OR AUTHORIZED PERSON HEREBY VERIFIES
THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE
BEST OF HIS OR HER KNOWLEDGE AND ACKNOWLEDGES THAT IF ANY OF THE
INFORMATION PROVIDED ON THIS FORM IS FALSE HE OR SHE UNDERSTANDS THAT THE
BUILDING PERMIT WILL BE IMMEDIATELY REVOKED AND ALL FEES PAID FORFEITED.
DATED this --T day of _ 20
PROPERTY OWNER/AUTHORIZED
PERSON
Signature
Print Name
WITNESS
Print Name
L:\TEMP\BUILDING\Handout Archives\HANDOUTS REVISED IN 2009\PREVIOUS HANDOUTS\FORMS\CONTRACTOR EXEMPTION
FORM D,DOCREVISED 7/07