1987, 01-12 Permit App: 87000074 Residence•1
(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
. 'PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERST
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
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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 to compile said application is true and correct.
u--/✓C-.�' Date
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Approved
Cond.
Approval
Hold
Environmental Health Application Of
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
' Engineers w�t���t7 /-
N. 811 Jefferson fG'/CM4- 60e, 74-2-
4- 6d %
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/Utilities
N. 811 Jefferson
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THAA
OTOm1� an-8.a."A.4T RE4tfu2isTi
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
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 to compile said application is true and correct.
u--/✓C-.�' Date
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProtect
Owner's Name Last First MI
Probed Address (Street Name & Number)
City
State
Subdivision/Plat Name
Assessors Parcel p
Lot
Block
Plat a
Applicant
Address
City
I State
Zip
Phone
Business Phone
Contractor
Address
City
I State
Zip
Phone
Contact
License N
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Drain(s): /
Wash! g Machine(s): /
Oeh Wshr(s): /
Garb Disp(s):
Kit Sink(s): /
Lndry Tray(s)'
Sew Eject(s):
Urinal(s):
Wtr Closet(s): G— n
Lev(s): 2_
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: V 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
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Himalaya Homes, Inc.
Address:
ale 3224 S. Pines
Legal:
Lot 4 , Blk 1., Midilome 4th
Scale:
1"
= 20
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