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1986, 09-30 Permit App: 00013420 Residence(THIS IS NOTA PERMIT) BUILDING PERMIT APPLICATION WORKSHEET PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND r COMPLETE IN INK (Please return this original and your building plans to the Department of Building and Safety) onn UCIJ f\n CMJ t% nC rvn u Cr F1 n 1 !VI CPI I MI- u0C y ll g6. n aWia Project Address (Street Name & Number) Zip t --S, rrt ea Zq (�.tso <..E Ili iziffisIFINIIMII Address $.re419 2— City...... CityState%� �� vE /+ W .. Zip 9Qzo'z-. Business Phone r CantractoogAgent COft./172 t'Q. Address ( City State Zip Phone 4 ' Contact c kTcE fIZA`l NC 2 Liceme Number (Required) CAT, >k /AzOP Business Phone < ) Architect/ Engineer a is 8-7 Address City State Zip Phone ( ) Contact Business Phone ( ) Lender Address City State Zlp Phone ( R°"o`, ..w '" t . ,'rrte�++•• �, :S" C .. .�t�A t j, .�. w,��r° § 6 t `z .�.s^rr ._.�.dnt"s ..y .E:''G�1.wI.5A'„t4:y,, >i'§w'fi',�$4�det+h^„s;4kF.d .n.'•yt+f..*�iN, .t w NY, Comm. y .n.St• >r �ti 5rY fk �.t 3t; �A t •} '"nN'R "T.,p +,i } Y;. Tf �.'%`ry:.>xa�`: x . s / {�r+ ' * �:..A. ^f. , . .YJ' y 0 4 t Yty f YX {, >4K 't �t n, ..' +4 ,� s ro•+ x �x #.* - .r^.... la{Number '•' fir r § '�� 't '$,pp'}6* i.,t ya•W^,�*YS.�k ,,,..� y• 47 JF'4 '7�£ nw�" a" 4'S•d .,t'q a a,F"-i. ztir"��' if°? j = fi (Mfr. � , . p"P.Ya'v °censTract ✓'� . , e a, OepTh sc: "s a Bulldings` .wed .} ELot Slisk( q. t (Acrer'f - � +"'� res...,-,.. dh gY.��fs,ggS'?hf }` ,;� e, a: q ,� r 'nt` �s �" "4 i »�t ", "aro N=t.rT � Frontage 9 • ..4. _ wN •R . S ..a..- ..,yw VVIdth , 5.5. ` ' �i '..9JM1 ^r Y fm. w .. • e'kf..f #,*£^ aYn` YL�+Ti^5y k x '"„� t✓�'.t'. pjq. kin• gh • ukr - oota9p:..e`a .,rrw..Ei ifi •' y�yF�f�''��ln* - : is . 'y+y ' 4 k ' ." +,ii.e a%�r�/ryj(�'j� 4,Yj�}�iy„RST[R.r 1 L 4 a*tl2t >} 1 >y'�:R °e t�� * ,'- L ,. ..i.s �gnt3.. �.,"`D aai ♦fa•T> r.K%s: t''C4FwT�- f 4 �,5•a�'J'�sL`�.sti RSxk ++j l��g�YRi .t1ij" ys.�� T� t'3.(�`•�(/�`(� n.� j s. 'S, hf i R dd. i4�S'uTF �•4 a^Y'}�v't 5 •J., ) k Stn^"i",��.�' 'z., .B"'-�Y.n�S�±§'t`i"h.t'#"16'^>�Wf��'.W4F"'!'g•U �. 4h_'C t 'vKMJa;iv?`� aYxq{i,R Y } rb i''} fy. ° -5r $$. ^''gu ��w �7'b,.377j+'k"v s t *, Nupbero roans k ave T wit <_k as ..:• ti' sa i = _'MS .x, ,` `Croup rid/. ri4nax Legal Description MEN 11111 11111111111Ou ■ :a.aas u)»a.:y;1.141..400te. Show on Site Plan: Additional Information: Landscaping Lot Dimensions 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 Legal Description MEN 11111 11111111111Ou ■ :a.aas u)»a.:y;1.141..400te. 4 4 < < O 0 Arvicx 1... _..1 uu �I 1 l3 I i ! 1 is Nso m W ' . m 0 J m - f, J W < S U o K!f731 1- 1 0 m 1 i 11.96 ° 6v....[ ut# �!Z�xir } 61!!...._&?Q7 • 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 Planning/Zoning 1 N. 721 Jefferson Engineers N. 811 Jefferson .�ia 6-J 0 9/ 36/ -----' Utilities ,Oa iv N..88111Jefferson / Plan Review/Fire Prevention N. 811 Jefferson /0 -moo f 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 / f' 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. f 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 I15-30HP 30-50HP I50+HP • Gas Piping 1-5 Outlets /, 6+ Outlets Gas Fired HeatingSystem 1-100,000BTU �rL 000 10�,,.AO+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 660 IProject Al O Owner's Name Last First MI Project Address (Street Name & Numbe ) City State Subdivision/ Plat Name Assessors Parcel II Lot Block Plata Applicant Address City I State Zip Phone Business Phone Contractor Address City I State Zip Phone Contact License a Business Phone Describe Work Bar Sink(s): Drinking Fountain(s): Floor Drain(s): / Washing Machine(s): l Deb Wshr(s): / / Garb Diep(s): / Kit Sink(s): / Lntlry Tray(s): Sew Elect(s): Urinal(s): Wt Closet(s): 3 Lav(s): 2 3 Shower(s): ' Tub(s): 2 Bidet(s): Other: Type; Waste/Grease Interceptor(s): i Sewer Y N Septic/ Health No.: I I Electric Water Heater(s): Drains -Roof: I 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 +: u. 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