1985, 07-19 Permit App: 00006461 Fire Damage Repair(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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
' Project Number 6 .&/
Owner's Name LAST FIRST MI
Project Address (Street Name & Number) Zip
r v, M,. LA --k
Applicant
t—i C I L)
City State
Address
\
Zip
Phone
Business Phone
( )
Contractor/Agent
Address
City
State
Zip
Phone
Contact
License Number ( e uired)
3—NSk"S 'w /6 I &M
Business Phone
( )
Architect /Engineer
Address
City
Contact
Lender
City
State
Zip
Phone
Business Phone
( )
Address
State j 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
Approved
Cond.
Approval
Hold
Environmental Health Permit Number
W. 1101 College
Room 200
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.)
I
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
PLUMBING PERMIT APPLICATION WORKSb
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YL.
Project #
Owner's Name Last First MI
Project Address (Street Name 4 Number)
<i — I,AtLAI ELLt
pity
r 6,-,m 2
State
(-1,0._ -
Subdivision/Plat Name
Aasessors Parcel #
Lot
Block
Plat #
Applicapt
IL.[2e Cos :,_- ,,;`
Address
E f 7 2-1 (ol?),..
City- I
State
Zip
Phone
Business Phone
Contractor /r
Ebz L ,oc).5
Address
- r,-1 *_-
City State
I
Zip
Phone
Contact
License #
Business Phone
Describe Work I_•
4.12251,‘
Bar Sink(s):
(Drinking Fountain(s):
Floor Drain(s):
,
Washing Machine(s):
Dish Wshr(s):
Garb Disp(s):
Kit Sink(a):
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
APPLICATION
DATE 5��