1987, 02-26 Permit App: 87000369 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) ,
got SHADED AREAS ARE FOR DEPARTMENTAL USE ,
�Froject'Nu"tuber y�
Owner's Name s
LAST FIRST MI
Project Address (Street N me & Number) Zip
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Applicant
Address
City
State
Zip
Phone
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Business Phone
Contractor/Agent
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
/
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
i
Lender
Address
City
State Zip
Phone
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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 applicay}en"is >'t ue and correct.
Date Z
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A oved Cond. Approval
Hold
Environmental Health Application N
W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
Engineers—.�/1//�c�iQ�
N. 811. Jefferson
7
Utilities
N. 811 Jefferson
77
Plan Review/ Fire Prevention.
N. 811 Jefferson
Other(SEPA/Critical Material/etc.)
Fast Track/S `� Ial 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 applicay}en"is >'t ue and correct.
Date Z
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PERMIT APPLICATION WORI
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Project #
Owner s Name > Last First MI
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City State r SubdivisionlatName
Assessors Parcel M
Lot
Block s
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Applicant
A ess
Address ,.
City
State
Zip _
Phone -
ZBusiJ'2 '2-
ness Phone --
Business
ContractAddress
City
StateZip
Phone
Contact
License N.
Business Phone
Describe Work .
BarSlnk(s):
Drinking Fountain(s): Q
Floor Drain (s):
Washing Machine(s): j
I
GarbDisp(s) CJ
KitSink(s): I
LndryTray(e): G>rSewEject(s)..DahWshr(s):
`.:
Urinal(s): ('i'`
WtrCloset (s):
Lav(s):
Shower(s):
Tub(s). / ..
Bidet(s): .'
Other: Type
Waste/Grease Interceptor(s):
Sewer Y Septic/Health No.:
Electric Water Heater(s): / `;
Drains -Roof:
1
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 18:1-5: