1986, 10-07 Permit App: 00013476 Residence(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
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DEPARTMENTAL REVIEW
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent to compile said application Is true and correct.
Signature Date
6 be I R6
ApprovedCond.
Approval
Hold
Environmental Health Application #
54-66
r/tiJlc
W. 1101 College
Room 200
/Planning/Zoning
N. 721 Jefferson
Engineers yy q
N. 811 Jefferson -//a--.3-3/
ccc/TTT
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Utilities
N. 811 Jefferson
p -'1-$b
r-0024/
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative -
Phone
Address
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent to compile said application Is true and correct.
Signature Date
6 be I R6
r
N
W
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1-
1-
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject k
Owner's Name Last First MI
Project Address (Street Name & Number)
City
State
Subdivision/Plat Name
Assessors Parcel a
Lot
Block
Plat If
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor Go LO SEAL N Ec'a
Address
City
State
Zip
Phone
Contact
License k
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(a):
Floor Draln(s):
Washing Machlne(s): /
Doh Wshr(s): /
Garb Disp(s):
Kit Sink(s): '
Lndry Tray(s).
Sew EJect(s).
Urinal (e):
Wt Closet (s): l 1
Levis): '
Shower(s):
Tub(s): /
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s): /
Drains -Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N
Lawn Sprinkler System(s), including backflow device on any one meter:
Vacuum breakers or backflow devices In excess of line 16:1-5:
(Or) 5 ♦ :
BASE 60A PO 46A
I certify that the above information as submitted by me is true and.correct and further, agree that all pro-
visions of laws and ordinances governing this type of work, including inspection requirements, will be com-
plied with whether specified herein or not. The granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
APPLICATION
OWNER OR AGENT DATE
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Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
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Scale: - •
Date:
Revisions: Attachments: '
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