1986, 09-15 Permit App: 00013696 Residence(THIS IS NOTA -PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
56 / - Sb
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)
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Project Number
Owner's Name LAST FIRST MI
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DEPARTMENTAL REVIEW
l'es
Approved
Cond.
Approval
Hold
Environmental Health Application # 5I ---/e)
W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson -
/Engineers yy�
N. 811 Jefferson TT"g C,Os
Utilities
N. 811 Jefferson
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Plan Review/Fire Prevention
N. 811 Jefferson
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Other (SEPA/Critical Material/etc.)
Fast Track/Special inspection Information
Protect Representative
Phone
Address
1 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.
Signature
� 4 Date
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Show on Site Plan:
Additional Information:
Lot Dimensions
Landscaping
Existing Structures
Drainage Plan
Proposed Improvements
Hydrants
Structure Setbacks
Topography
Easements
Lighting
Septic System (s)
Signage
Water Lines
Shorelines
Sewer Lines
Highwater Mark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject ff
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
Address
City
I State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Crain (s): /
Washing Machine(s): /
DO Wshr(s): /
`
Garb Disp(s):
Kit Sink(s):
1
Lndry Tray (s): I
Sew Eject(s):
Urinal(s):
Wtr Closet (s): %%
L—
Lav(s):
Shower(s): /
Tub(s): g
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/ Health No.:
Electric Water Heater(s): f
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:
(005+ :
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