1986, 10-07 Permit App: 000013632 Residence i
(THIS IS NOT A PERMIT) �
BUILDING PERMIT APPLICATI®N 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 n
Project Number /5�3 G—
Owner's Name LAST FIRST M I
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Project Address(Street Name&Number) Zip
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Applicari Address
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C' State Zip Phone
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Business Phone
Contractor/Agent Address
City State Zip Phone
Contact License Number(Required) Business Phone
la - \A -f,- )......):5 NS PCone
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
Lender Address
City State Zip Phone
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Ntn� Lot Block Plat Number
Zone Comp.Plan Census Tract
U ttis Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
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� LeftSeihack�'� . RightSetbackl' Rear Setback R/WWidth
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square Footage
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F$ m Number of Bedrooms
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DEPARTMENTAL REVIEW
Approved CpApproval Hold
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Environmental Health Application$ g—/136 /(2-- 741
W.1101 College rde)"..._)
Room 200
Planning/Zoning
❑ N.721 Jefferson
r):4Engineers ,,�.n4 /4
N.811 Jefferson `r Y /
Utilities I
❑ N.811 Jefferson
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Plan Review/Fire Prevention Pelf❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
0
❑ 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.
Signature Date
f
a
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject#
Owner's Name Last First MI
Project Address(Street Name&Number)
City State Subdivision/Plat Name
Assessors Parcel# Lot Block Plat#
Applicant Address
City State Zip Phone
Business Phone
Contractor Address
It. J. 13. PLS
City I State Zip Phone
•
Contact License# Business Phone
Describe Work
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s): /
Dsh Wshr(s): / Garb Disp(s): Kit Sink(s): I Lndry Tray(s): Sew Eject(s):
2Urin ( 32-
Urinal(s):
al(s): WtrCloset(s): j Lav(s): ' Shower(s): Tub(s): ' Bidet(s):
u) Other: Type;
CC
I- Waste/Grease Interceptor(s):
U
u- Sewer Y N Septic/Health No.:
CC
W m '
Electric Water Heater(s): Drains-Roof:
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: (00 5+:
EASE 60.4-RD /4T
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 APPLICATION
OWNER OR AGENT DATE
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