1986, 12-03 Permit App: 00014399 Residence(THIS IS NOTA PERM[ -1 )
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
City
State
Zip
Contractor/Agent
C.9/ze.
City
State
Contact
Architect/ Engineer
City
Business Phone
Address
/ COLLA
L ' ?
Zip
Lice e Number (Required)
Phone
(
)
Business Phone
(
State
Address
Zip
Contact
Phone
Business Phone
ubdivisian/Plat Name/Sh rt Plat Number
DEPARTMENTAL REVIEW
I certify that 1 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
• Date
Approved
pp
Apprrovov al
Hold
Environmental Health Application #
W. 1101 College
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Room 200 —TQ64T/-IELA1'
Planning/Zoning
N. 721 Jefferson
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N.811 Jefferson 7/y�
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N. 811 Jefferson
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Plan Review/Fire Prevention .
N. 811 Jefferson
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Other (SEPA/Critical Material/etc.)
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Fast Track/Special Inspection Information
Project Rep....,,reeentative•
. Phone
Add�ees sNa
I certify that 1 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
• 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
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
3 Pit-lIAAJ'S PLEG
Address
City
I State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s): /
Washing Machine(s): /
Deh Wshr(s): 1
Garb Disp(s): /
Kit Sink(s):
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
2
WtrCloset (s): 3
Lav(s): 3
Shower(s): /
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 Plping/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
co
W
Q
F-
X
LL
u.
0
ccW
m
i
z
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
# 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 1
State
IBusiness
Zip
Phone
Phone
Contractor
Address
City I State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s):
Washing Machine(s):
Dsh Wshr(s):
Garb Disp(s):
Kit SInk(s):
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
WtrCloset (s):
Lav(s):
Shower(s):
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:
(00 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
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
Contractor`'`
�I ?
Address
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr. ./
Solid Fuel /Wood Stove
Air Handling Unita
0-10,000 CFM
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
`�
6 + Outlets
Gas Fired Heating System
1-100,000BTU
10..,0300+ 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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