1986, 11-21 Permit App: 00014314 Residence(THIS IS NOT A 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)
Project Number
Owner's Name LAST FIRST MI
UC.)LjQSs 4-ka-
Project Address (Street Name & Number) Zip
Sou -rt -t 3241 (L i, PPLO- Or- -ii2e6,,
Applicant 9 /316 / I
/10At 4
Address
City
State
Zip
Phone
( )
Business Phone
( )
Contractor/Agent
-V.R.,‘Pfkkr06u45s
3-,c(1, eJ
Address
8/ Jaz
City
(/ jf��92
Statea�
Zip
Phone
Contact
grketey �4 s
License Number (Required)
*Q-1-41
kND k
Business Phone
)
Architect! Engineer
Auuress
City
State
Zip
Phone
1 1
Contact
Business Phone
( )
Lender
Address
City
State I
Zip
Phone
(
Describe Work
Si 17)E-k)e— Le) (014-1Vr�',,&
Res.
Comm.
Subdivision/Plat Na e/Short Plat Number
i0 ttin AU� 4111
Assessor Parcel Number �Q
3364/-2&,q
Lot
Block
1
Plat Number
Pertinent File Numbers
Zone
r-""1?
Comp. Plan
Census Tract
Number of Dwelling Units /
1
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Front Setback 3o
Left Setbac�3
Right Setba
22
Rear Setback
R/W h
Wi t
Additional Information
SE; ,1,-s C— L1 -U41- 0Letic —JT"
Square Footage
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IC)OCI tiR3
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P
542_ GAe
2
cr
0
LL
Z_
0
Z_
3
-J
5
in
Number of Bedrooms
.BuildingTechnician
Date
Group
2-3
Type
urJ
Show on Site Pian:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic'System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Widths)
Names of
Fronting Street
Flanking Street
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
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 compile said application is true and correct.
Signatu
Date Yc
Approved
Cond.
Approval
Hold
Environmental Health Application M
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers.11f ;1‘'_ �4;, 6/r
N. 811 Jefferson
// ..71 ,'
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Utilities
N. 811 Jefferson
r{{.
a4/iG 5,a) r` fir
/ Plan Review/ Flre Prevention
N. 811 Jefferson
i�
k&T
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.
Signatu
Date Yc
rn
w
1-
CCH
X
ctw
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2
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
l State
Zip
Phone
Contact
License #
Business Phone
Describe Work
BarSink(s):
Drinking Fountain(s):
Floor Drain(s):
Washing Machine(s): /
Dah Wshr(s): '
Garb Disp(s): 11
Kit Sink(s):
/
Lndry Tray(s):
Sew Eject (s):
Urinal(s):
Wtr Closet (s): /7
,L_
Lav(s): �
Shower(s): �
1 Tub(s): I7
4�
Bidet (s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/Health No.:
Electric Water Heater(s): J
/
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:
(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
MECHANICAL PERMITAPPLICATION 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
0-10,000 CFM
10,000 + CFM
Refrigeration Systems/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15-30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets 1
6+ Outlets
Gas Fired Heating System
1-100,000BTU /
10v,�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