1986, 03-10 Permit App: 00010031 Residence(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTANDS 1 1
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
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project NumberN-,
e LAST
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Project Address (Street Name & Number) r Zip
q , 3426 f 0 k C i .
Applicant
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frgdress r.
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State \
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Phone 6b5 (03 3-25-bq ._. J
Business Phone(5.)
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/Agent
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PhoneZt
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Contact-,��
S�License NUmber IC.G.JV(
.(Required)_ / ��
Business Ph� „ / 3 _ l ^S—
ecEn neerkboL{.•[fes[/)`/P
WOO
et
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State
Phone
Contact
- usiness Phone
Lender
Address
City
State
Zlp
Phone
(
Describe Work�'''y
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Comm.
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number
335y 1- ocio‘
Lot
Cer
Block
(
Plat Number
Pertinent File Numbers
Zone
445, Fe -
Comp. Plan
Census Tract
Number of Dwelling Units
\
Number of Buildings
1
Lotilze (Sq. Ft./Acre)
1212,EG) .
Depth
Frontage
Front Setback
30'
Left Setback '
LV
RightSetbick?
W •
Rear Setback
R/W Width
-
Additional Information
I BUILDING INFORMATION
Square Footage
i31f� #1 t.41
9
:47 us
528 $ C4I
Number of.Sedrooms
Building Technician Date//
2 . %- 1.903/s45/10/86
Group
� '3
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El
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 co e said application Is true and correct.
Signature
Date
Approved'
Cond.
Approval
Hold
Environmental Health Application p
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
tel
VE2tel 201 SETSAUC
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Engineers / G'�7� .ol p
N. 811 Jefferson ��./ /J
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Utilities
N. 811 Jefferson
' h-er
Plan Review/Fire Prevention
- N. 811 Jefferson
I
ine
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 co e said application Is true and correct.
Signature
Date
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X
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
toy 1
10
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
Project a
Owner's Name Last First MI
Project Address (Street Name & Number)
City
State
Subdivision/ Plat Name
Assessors Parcel s
Lot
Block
Plat if
Applicant
Address
City
I State
Zip
Phone
Business 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 WaM(s)j
Garb Dlsp(e):
Kit Sink(s):
I
Lndry Tray$): t
Sew Eject(s):
Urinal(s):
W1r Closet(s): Z
Lav(s): 2
Shower(s): — I
Tub(s): '1
1
Bldet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater (s): I
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.
(005 +:
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10
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
PP:O PERTY1 _
T H -AV6.
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