1985, 07-24 Permit App: 00006537 Addition(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)
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VJC I Project Number
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Owner's Name LAST FIRST MI
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Project Address (Street Name 8, Number)
Zip
Applicant
Address
City
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State t
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Zip
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Phone
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Business Phone
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Contractor/Agent
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Address
City
State
Zip
Phone
(
)
Contact
License Number (Required)
Business Phone
(
)
Architect /Engineer
Address
City
State
Zip
Phone
(
)
Contact
Business Phone
(
)
Lender
Address
City
State
Zip Phone
(
)
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 is true, correct, legal, and binding.
Owner's Signature Date
ApprovedCond.
Approval
Hold
Environmental Health Permit Number eaci-?9‘,
- W. 1101 Collegefti
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Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
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 is true, correct, legal, and binding.
Owner's Signature Date
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PLUMBING 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 other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR AGENT DATE
APPLICATION
1 Project #
Owner's Name Last First MI
Project Address (Street Name & Number)
City
State
Subdivision/ Plat Name
Assessors Parcel 8
. Lot
Block
Plat #
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor
Address
City
I State
Zip
Phone
Contact
License #
Business Phone
Describe Work
BarSink(s):
Drinking Fountain(s):
Floor Draln(s):
Washing Machine(s):
Dsh Wahr(s):
Garb Diep(s):
Klt Sink(s):
Lndry Tray(s):
Sew Eject(s):
Urinal (s):
WtrCloset(s): '
Lav(s): I
Shower(s):
1
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+:
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