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)
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Legal Description
MEN 11111
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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
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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
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
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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