1985, 04-29 Permit App: 00005140 AdditionBUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name (last) (first) (m)
ST sills()Ai ,ctouc
Cepartment Only
it,s.
Comm
2 Project Address (not Mailing Address) cr Road Name�Space Zip
071/UP3 (°. e,vf e,e)_ P GJZJ2
3 City/Comm
>�aNe�
State Subdivision/Plat Name
'�Ne . r /4 , /f `�
4 Assessor Parcel
01592 _ /(0O
I
Lot
Block
♦ + + DEPARTMENT USE ONLY * * *
5 Sic Code/
Zone Act. N
Zone J_ti
/ ,8
Project No. - _%./5
6 Dwell p
1
No. of Buildings
2
Sq. Ft./Acre
Depth
1300 I
Frontage )
10
7 Set Back -Front I (L)S 1
tX 1/11QG 4
(R)S-2 1 I Rear '
Co
Census Tract
Module No.
Is ` -
Initials
UNI rin
16 Architect Firm Name Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
Contractor FIcm Name
if U(5/ 2 ) 1 ) ST
Street Address
/ 414 , R St' ,N7- 12.r)Zip
/�/j � I 8"Gty
piA-su
State
1,U
Phone
( I
Contact
Pal
P
Person cid
tit ,i,U)
License No.
C CO /Uoothc J(4 3
Phone if different than above
(Sol) S€6,6094a
8 Owner/Agent (If different than 41 above) Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
I SEPA Exempt (Y/N)
Date
15 Type Work 0 Bldg
0 Fire
0 MH
0 Demo
0 New
Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work 11 i ,yy
S uto 5 3!45 6 P-14-1'/-1 �Dn - �,-)a) 2 0 '1'
10 Applicant Name /
Street Address
11 Zip
City
State
Phone
1 )
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
1 )
Additional Information
l
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (First) (M)
Department Use Only
,. t(Last)
Si eA SOA) Si: c.AJC:
Project No.
2 Project Address (Not Mailing Address) Space Zip
I•4 09 A) 1 ,0A14e2
3 City/Community
9 J(4AJf
State
VI
Subdivision/Plat Name
4 Assessor Parcel.No.
I Lot
Block
16 Contractor Firm Name
Jo I4R
cotti Am aC3N1.3t
Street Address
E 141'/ 14-475f:4 eis 40
17 Zip
/%�
[ C/02 i �
City
C o/(1-rN-.)F
State
IA ,L)
Phone
sfi) g66 69 4?
18 Cont ct Person
7-JeA 0 ( L) C Cy 1 u;u;n
License No.
COO t IN02.1-1C Roc; J3
Phone if ddferent than above
8 Owner/Agent (If different than 41 above)
Business Address
9 Zip
City
I State
Phone
( I
15 Describe Work: New 0 , Addition/Alteration 0 ; Replace/Repair 0
Total Number
of Fixtures:
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
9 Bar Sink(s):
Drinking Fountaln(s)•
Floor Drain(s)•
Washing Machine(s)
10 Dsh Wshr(s):
Garb Disp(s):
Kit Sink (s).
Lndry Tray (s).
Sew Eject (s).
11 Urinal(s):
Wtr Closet(s): J
Lav(s)•
I
Shower(s): 1
Tub(s)
Bidet (s)•
Other: Type,
12 Waste/Grease Interceptor(s):
13 Sewer Y N Septic/Health No.
14 Electric Water Heater (s)•
Drains -Roof'
15 REPAIR OR ALTERATION: Drainage, Vent, Water Piping/Treatment: Y N
16 Lawn Sprinkler System(s), Including backf low device on any one meter:
17 Vacuum breakers or backflow devices in excess of line 16: 1-5'
(Or) 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
APPLICATION
OWNER OR AGENT DATE
°Lp
i2 o pip