1986, 08-14 Permit App: 00012671 Residence(TI -IIS IS NOT A 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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Owner's Name
LAST
FIRST
Address
MI
Zip
99,26 co
Applicant
Llr-zi,e( may? Co0 c 4 o 1 (p,Box.sca .� P/i/d �-
City State Zip Phone
SxKa it)ct, 9 x-21 o/ 30 9 ( > 91e- 2J-
Business Phone
Contractor/Agent
-t- roc{ i o v�
Sta - Zip
6KC-Vi-Q
Cont I License Number (Required)
Pr) i'Ir L(rcte(roan Lin eJL33p
Architect /Engineer
State 0/1
Business Phone
(6° 9) 2 96
Address
Address
Zip _7,7 Phone rbc? <--/g3 3 - di>
Lender
State
Business Phone
Address
Zip Phone
Assessor Parcel Number
Num
Number of Dwelling Units
Building Techn
DEPARTMENTAL REVIEW
1 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 application is true and correct.
Signature
Go.i.5.6)(ks- Date g —PI I -AW
Approved
pp
Apprrovov al
Hold
Environmental Health Application 1
W. 1101 College
Room 200 kif Q'
Planning/Zoning
N. 721 Jefferson
/Engineers�� `/y
N. 811 Jefferson
/
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
5--1s'Esfr
Other (SEPA/Critical Material/etc.)
Fast Track/Special inspection Information
Project Representative
Phone
Address
1 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 application is true and correct.
Signature
Go.i.5.6)(ks- Date g —PI I -AW
9/- 6 9
- -4
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0
11
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4- -1
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MECHANICAL 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 state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
APPLICATION
OWNER OR DATE
Project #
Owner's Name Last First MI
Project Address (Street Name & Number)
City
State
Subdivision /Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
State
Zip
Phone
Business Phone
ContractorAddress
4We.0Do0F
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furna e/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
1
6+ Outlets
Gas Fired Heating System
1-100,000BTU
1
10;,0
,,0+ 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
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
4
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
Project #
Owner's Name Last First MI
Project Address (Street Name & Number)
City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor �f
tC,& 1 ® 6� fi,
Address
City
I State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Bar Sink (s):
Drinking Fountain(s):
Floor Drain(s): I
Washing Machine(s): I
Dsh Wshr(s): I
Garb Disp(s):
Kit Sink(s): )
Lndry Tray(a):
Sew Eject(s):
Urinal(s):
WtrCloset(s): 3
Lav(s): �
Shower(s): z
Tub(s): I
Bidet(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:
(00 5+:
4
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