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.ot. <br />A M <br />0�b \� DEVELOPME deb <br />c, T SERVICES <br />-�: PLUMBING, MECHANICAL, TANK, & DEMOLITION. cS <br />PERMIT APPLICATION i <br />121 5"' Avenue N, Edmonds, WA 98020 <br />Phone 425.771,02201Q Fax 425.771.0221 <br />City of Edmonds <br />PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS <br />PROJECT ADDRESS (Street, Suite #, City State, Zip): B�Zo <br />Parcel #: <br />IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No <br />VG��aC <br />APPLICANT: <br />BA14 K .AMA �- "A <br />Phone: <br />�PS-_ Gn �Z G <br />Fax: <br />Address (Street, City, State, Zi ): <br />P fa LIZ ,1) In G A/))_5 W A <br />Mail Address: <br />L9/? r �-:j ✓o' ^�,�. C. <br />PROPERTY OWNER: <br />Phone: <br />Fax: <br />Address (Street, City, State, Zip): <br />E-Mail Address: <br />.ENI G AGENCY: <br />Phone: <br />Fax: <br />A dress (Street, City, State, Zip): <br />E-Mail Address: <br />CON RA TOR•* <br />Phone: <br />Fax: <br />rv"r- <br />Address (Street, City, State, Zip): <br />E-Mail Address: <br />WA State License #/Exp. Date: <br />*Contractor must have a valid City of Edmonds business license prior to doing work <br />City Business License #/Exp. Date: <br />in the City. Contact the City Clerk's Office at 425.775.2525 <br />PLUMBING MECHANICAL TANK <br />DEMOLITION <br />oaasy- <br />DETAIL THE SCOPE OF WORK: L ` <br />l.Ji OG�.� a 'ts, > .� <br />0� <br />C�v��--%t�� /o�,�, .ti.P <br />I declare under penalty of perjury laws that the information I have provided on this form/application rs true, correct and complete, <br />and that I am the property owner or duly authorized agent of the property owner to submit a permit application to the City of <br />Edmonds. <br />Print Name:_ r O��✓ OwnerofAgent/Other ❑ (specify): <br />Signature: - -s Date: <br />FORM C LABuilding New Folder 201000NE & x-ferred to L-Building-New drive\Form C 2014.doex Updated: 1/17/2014 <br />