1986, 08-04 Permit App: 00012476 Reisdence(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)
J I-1 /-1 Ll C V M 1-11L "'AO M fI C F Li f1 V L. r Mn I IV C I V I ML LI Cl L.
Project Number
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Owner's Name LAST FIRST MI
Project Address (Street Name & Num t3 er) Zip
IVU e_ -r --ti 5 t/-? it /?E-ES 0 T- Q6 2!40
Applicant
Psc►Gk1�ic,,4L
Address
E' ,5---/e ii /C�c J 1
City �U'/�/��S
d� StateAZip
Phone (6-d?)
Business Phone
( )
Contractor/AgentAdd
7 S eliksi j�ic
l/9R
ess
-)-3-701.-) R1 G 1-/
City
�1 CH i 1 NE
State
cv
Zip
q 5-7
Phone
(6--6) g 6- 6z/
Contact
License Number (Required)
Business Phone
( )
Architect/EngineerAddress
2Jam/
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f�
City
/vs
State
/A-;s)z
,
Zip
S5:
�
Phone
(6-65) Sz; ,2sr
Co tact
Business Phone
( )
Lender
Address
City
State I
Zip
1
Phone
( )
Describe Work_
�j.
K�+r. 4 (Thr-, lh ✓ ai/C »444 .
Res.
Comm
Subdivision/Plat Name/Short Plat Number
-)41—)A-0 Ac -s 3RD ADO
Assessor Parcel Number
pp�� p
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Lot
Block
it
Plat Number
Pertinent File Numbers
Zone , -
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft. /Acre)
Depth
r
Frontage
,/ E.
Front Setback
Left Setback
Right Setback
Rear Setback
R/ W Width
Additional Information
IBUILDING INFORMATION
Square Footage
1526 a5 kir
Number of Bedrooms
Bul :.rg Technician
� } ..
Date
Group
R 3
Type
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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.
Date
/1.7y. 614
Approved
Cond.
Approval
Hold
/
i Environmental Health Application # —ao l
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W. 1101 College
Room 200
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' Planning/Zoning
N. 721 Jefferson
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Engineers
/L� ,/�
N. 811 Jefferson /` 7 y
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Utilities
N. 811 Jefferson
Plan Review/ Fire Prevention
N. 811 Jefferson
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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.
Date
/1.7y. 614
1,.) .ACR S 3 it r) . ADD,
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
fProject #
Owner's Name Last First MI
. Project Address (Street Name & Number)
City
State
Subdivision/ Plat Name
Assessors
Assessors Parcel#
Lot
..-
Block
Plat #
Applicant
Address
City I State
Zip
Phone
Business Phone
Contractor
P___.
Address
_j/k11 7---
-
City State
7
Zip
Phone
Contact
License #
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountaln(s):
Floor Drain (s): /
Washing Machine(s): /
Dah Wshr(s): /
Garb Dlap(s):
Kit Sink(s): /
Lndry Tray(s): /
Sew Eject(s):
Urinal (s):
,# ►
Wt Closet(s): 2.....
L•
Lav(s): I)
2._
Showwer(s): /
Tub(s): /
Bidet(s):
(0
W
CC
Other: Type;
0
XWaste/Grease
Interceptor(s):
11
O
Ir
Sewer Y N Septic/Health No.:
ILI
COElectric
Water Heater(s):
Drains -Roof:
D
Z
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:
(Or) 5+:
eA-5 e60A e / EAT
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
�A APPLICATION
/ /', DATE