1986, 08-07 Permit App: 00012575 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 DEPARTN
1 Project Number
Owner's Name LAST FIRST
:f / L . RIO V 41f6^r.e Y7Oil
Project Address (Street Name & umber) Zip /
Applicant
Address
City
State
Zip
Phone
( )
Business Phone
( )
Contractor/Agent
Address
/
City
di
State
Zip p ? C
Phone 61 e q C‘
Contact
License Number (Required)
/
Business Phone
( )
Architect/ Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Add ess
City
State
Zip
Phone
(
the Work
�k0 Ci'VC,E'
Res.
✓
Comm.
bdivision/Plat NamelShort Plat Number
�f� . C -0.. e. pap c) I T ( o ns
tAssessor Parcel Number
Lot
Block
I
Plat Number
Zone
Comp. Plan
Census Tract
!Tibet of Dwelling Units
Number of Buildings
;
Lot Size (Sq. Ft. /Acre)
Depth
C 10 ,
Frontage
LCo,O
t Set
Left Setback
. 14''
Right Setback
4 I I
Rear Setback -
R/ W Width
• Mortal Information
1 BUILDING INFORMATION 1
Square Footage
Number of Bedrooms
Ing Technl.
S
Date r
��
Group
(((
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
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers o
N. 811 Jefferson 12. V70
9/y
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention I`/.--e,,e0i/-5-0(
)IN. 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
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject #
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
Zip
Phone
Business Phone
Contractor
Address
City
I State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s):
Dsh Wshr(s): I
Garb Disp(s):
Kit Sink(s):
1
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
WtrCloset(s): 5
Lav(s):
Shower(s): k I
Tub(s):
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s): l
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:
(00 5+:
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
OWNER OR AGENT DATE
APPLICATION
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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 state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION
DATE
Project #
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
Zip
Phone
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods(
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
I
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+ HP
Gas Piping
1-5 Outlets
6 + Outlets
Gas Fired Heating System
1-100,000BTU
10v,,00 + BTU
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 state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION
DATE
r r -
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