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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��