1986, 08-25 Permit App: 00012847 Residencen
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(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE 114 INK
(Please return this original and your building plans to the Department of Building and Safety)
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Contact
License Number (Required)
Business Phone
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Contact Business Phone
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Address
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Show on Site Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Linea
Fence's, Wails
Driveway(s)
Night of Way Width(s)
Names of
Fronting Street
Flanking Street
Legal Description
Additional Information:
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.
Signature
Date
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
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Planning/Zoning
1 N. 721 Jefferson
• Engineers �//
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N. 811 Jefferson .‘,--444 ! (o�
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Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
y--V-7,-S-0
(2-e6
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.
Signature
Date
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
WYE -115
F+ -r( -1 -
Address
City
State
Zip
Phone
Contact
L) q ikT C
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
'. ' O O
6+ Outlets
Gas Fired Heating System
1-100,000BTU
CA• o)
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
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 t 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
I State
Zip
Phone
Business Phone
Contractor
(a oI—C) S ff +ArL MCC -AA- AAN) 1. 4 L
Address
City
I State
Zip
Phone
Contact
License #
Business Phone
Describe Work , [� ,5 v �,
/`Drinking
BarSlnk(s):
Fountain(s):
Floor Drain(s): 2_---
Washing Machine(s): l
Dsh Wshr(s): (
Garb Dlsp(s):
Kit Sink(s): I
Lndry Tray(s):
Sew EJect(s):
Urinal(s):
Wtr Closet (s): --J
Lav(s): ;
Shower(s): IL_I
Tub(s): I
Bidet(s):
Other: Type;
Waste/Grease Interceptor (s):
Sewer Y (N Septic/Health No.:
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:
(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