1986, 12-01 Permit App: 00014513 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)
..... .......... ...._.....r..,_,,.,,.i.,".I,,1-../.,L 'Project Number //I/5LS
Owner's Name ( LAST FIRST
FIRST M I
s." #7C
Project Address (Street Name & Number)
/ /^ ^ ^ , Zip
i 4.=.3 +" � � �� l ��T�1V .
Applicant
Address
City
State
Zip
Phone
( )
Business Phone
( )
Contractor/ Agent
Address
City..
State
Zip
Phone
Contact
License Number (Required)
n iJ *(._(4,L
1 ss eiZ
Business Phone
(
Architect/Engineer
Address
City
•
State
I Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
(
�� � :
Res.
Comm.
Subdivision/Plat Na ne/short Plat Number
Assessor Parcel Number
4 .' C 1-3 ,
Lot 1
7 t
Block
i
Plat Number
Pertinent File Numbers
Zone
U
Comp. Plan
Census Tract
Number of Dwelling tjnits
Number of Buildings
(
Lot Size (Sq. Ft./Acre)
Depth
/27
Frontage t
do
Ftpnt Setback • ' . t
Left Setback
(G '
Right Setback
Rear Setback_
R/ W Width
60 f
BUILDING INFORMATION
Square Footage
a
.
2F /643
C6vCIZE
�� 25
eg
Number of Bedrooms
g ,E
Group
Type
.YYII
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 a . • • tion is true and correct.
Signature
Date ////,1----‘-'
Approve
Cond.
Approval
Hold
Environmental Health Application N t ‘O__74./
p
W. 1101 College
Room 200 /72
/�
Planning/Zoning1L
N. 721 Jefferson S C Lk (CDc�1Oi i l
go
'2A-
Engineers j
N. 811 ff rson ` s/ i�:-/„_ _air._%v • ” 1
-.
i- j /
1.
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I / /' .0-7�s..r.1
4
414
C � fora p ac T J /vas '4* e' n- IS,.Eswo» ti 4«. M... "-I 1018
C 8S1 -
Utilities
N. 811 Jefferson
/ Plan Revlew/Fire Prevention
N. 811 Jefferson
11//1
/91/3/g
U 6(7.t t iC) tcutSS -b '-c L -z,---24:1--
z --Other(SEPA/Critical
Other (SEPA/CriticalMaterial/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 a . • • tion is true and correct.
Signature
Date ////,1----‘-'
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
fProject N
Owner's Name Last First MI
Project Address (Street Name & Number)
City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat#
Applicant
Address
City
State
IBusiness
Zip
Phone
Phone
Contractor
Address
City I
State
Zip
Phone
Contact
License N
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s):
Washing Machine(s): I
Dsh Wshr(s):
Garb Disp(s):
Klt Sink(s): t
Lndry
Tray(s):
Sew Eject(s):
Urinal(s):
Wtr Closet (s): 2
Lav(s): 'L
Shower(s):
Tub(s): /
Bidet(s):
rn
IL
IY
Other: Type;
0
XWaste/
Grease Interceptor(s):
L
0
CC
Sewer Y N Septic/HealthNo.:
MElectric
Water Heater(s): /
Drains -Roof:
7
Z
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:
(00 5+:
E ee-rP((t EAse€OARO
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
PA 7
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