1986, 11-12 Permit App: 00014235 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)
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LAST
Owner's ,42 in( --5 /7 /7(7d ' FIRST Mi
Pro(ea Address (Street Name & Number) Zip
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Applicant
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Address
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City
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Zip
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Phone
(..531 9'2g s-7.(-0
Business Phone
1 (7) 7/ //
Contractor/Agent
/ �o� 7 4,(/nr
Address
City
State
Zip
Phone
( )
Contact `
License Number (Required)
Rilletirc. CT 1G4 c4
Business Phone
( )
Architect/Engineer //
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Address
City
State
Zip
Phone =
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Contact
Business Phone
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Lender
Address
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.Describe Work 3 t_`...• -..:.Q. , y_..w. ; _ ..,,, n, r: � . . ,.: • ." . .. _. .Ras,
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Lot Size(Sq. Ft./Acre)
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•Right Setback-
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T•��BUILDIND INFORNIATIO
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DEPARTMENTAL REVIEW
Room 200
Planning/Zoning
N. 721 Jefferson
1 1 1
Engineers ) 0
N. 811 Jefferson Ii-- )761/4
f6 bl� �o
0
Utilities
N. 811 Jefferson
1 1 1
Plan Review/Flre Prevention\ j . (,/
N. 811 Jefferson W� ,(N"`�"'
Other (SEPA/CFItIcal Material/etc.)
Fast Track/Special Inspection Information
Project Representative
I Phone
Address
I certify that I have examined this application an tate that the information contained in it and submitted
by me or my agent to co pile said appli o•. st •e and correct.
Signature
Date
Approved
Cond.
Approval
HOItl
/ i4" }/o
s F
Environmental Health
1
Application #8%-
QG
W. 1101 College
11-i L -
Room 200
Planning/Zoning
N. 721 Jefferson
1 1 1
Engineers ) 0
N. 811 Jefferson Ii-- )761/4
f6 bl� �o
0
Utilities
N. 811 Jefferson
1 1 1
Plan Review/Flre Prevention\ j . (,/
N. 811 Jefferson W� ,(N"`�"'
Other (SEPA/CFItIcal Material/etc.)
Fast Track/Special Inspection Information
Project Representative
I Phone
Address
I certify that I have examined this application an tate that the information contained in it and submitted
by me or my agent to co pile said appli o•. st •e and correct.
Signature
Date
I
Show on Site Pian: Additional Information:
Lot Dimensions Landscaping
Existing Structures Drainage Plan
Proposed Improvements Hydrants
StructureSetbacks Topography •
Easements Lighting
Septic System (s) Signage
Water Lines Shorelines •
Sewer Lines Highwater Mark
Fences, Wells
Driveway(s)
Right of Way Width(s) — —
Names of
Fronting Street
Flanking Street
Legal Description
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
• I Project #
Owners Name Last First MI
Project Address (Street Name & Number)
City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat 0
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor
Address
City
I Slate
Zip
Phone
Contact
License 0
Business Phone
Describe Work
Bar SInk(s):
Drinking Fountain(s):
Floor Draln(s):
Washing Machine(s): d
Dsh Wshr(s): I
Garb Diep(s): I
Kit Sink(s): I
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
Wt Closet(s): 3
Lav(s): 3
Shower(s): I
Tub(e):
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
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
e•,2
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
APPLICATION
OWNER OR DATE
Project/0
Owner's Name last First MI
Project Address (Street Name & Number)
City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat p
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 Wate Htr.
Solid Fuel/Wood Stove
2
Air Handling Units
0-10,000 CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
10t -500M
501-1,000M
1,001-1750M
Over1750M
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
1060:00 +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
APPLICATION
OWNER OR DATE
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