1986, 11-21 Permit App: 00014313 Residence(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)
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Project Number A/31?
Owner's Name LAST FIRST MI
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Project Address (Street Name & Number) / n Zip
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Applicant G7L j! Zit./
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Address
City
r State
Zip
Phone
( )
Business Phone
( )
Contractor/Agent
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ess
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City
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State
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Zip
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Phone
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Contact
License Number (Required)
4/ L,M AP 3ei13�a3
Business Phone
( )
Architect/ Engineer
Address
City
State I Zip
I
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
Describe Work
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Res. ty
Comm.
Subdivision/Plat Name Short Plat Number
r O 1 Lo )48 Ltri-1
Assessor Parcel Number
3351/i — 2P01
Lot
/ I
Block
Plat Number
;Pertinent file Numbers
Zone
SFr'
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
.Front Setback
Left Setback 2.0
Right Setback
tback
3
Rear Setback
R/W Width
Additional Information
SAuE As Vett (iE ( MEST
BUILDING INFORMATION
Square Footage a
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1009 LiFe
54-2- (• M:
Number of Bedrooms
8ulldingTechnic
Date
lI
Group
Type
Show on Site Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Legal Description
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shotoiines
Highwater Mark
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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 co ' a ile said application is true and correct.
Signature
Date
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
811 Jefferson Z'' ` / ZO 6' if?
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Utilities
N. 811 Jefferson
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I
el/3L/Z' ver- ceJ,
//Plan Review/Fire Prevention
N. 811 Jefferson„
/6-36-8tf,
-
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 co ' a ile said application is true and correct.
Signature
Date
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
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 Drain(s): /
Washing Machine(s): I
Dsh Wshr(s): i
Garb Disp(s): I
Kit Sink(s):
Lndry Tray(s): 1
Sew Eject(s):
Urinal(s):
WtrCloset(s): l%
c�
Lav(s): it
!�
Shower(s): /7
Tub(s): 2_
Bidet(s):
� Other: Type;
Waste/Grease Interceptor(s):
i Sewer Y N Septic/Health No.:
t 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:
(0115 4- :
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
J
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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 state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
APPLICATION
OWNER OR DATE
Project #
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
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/ Ducts
Miscellaneous
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/ Wood Stove
Air Handling Units
0-10,000CFM
10,000+ CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15 H P
15-30H P
30-50H P
50 + HP
Gas Piping
1-5 Outlets 1
6+ Outlets
Gas Fired Heating System
1-100,000BTU 1
10,,;,00+BTU
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 state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
APPLICATION
OWNER OR DATE