1987, 01-27 Permit App: 87000226 Residence YO—
(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF I HE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE �/��
Project Number =�J
dhvner's.Name LAST
FIRST MI
Project Address(Street Name 8 Number)
5 3 � 7 uJ fl �c �—�— . Zip
Applican
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City �C' State z11399:26,„
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1 j• r� Phone
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Business Phone
Contracto /Allent ( )
,.._--r 1 Address
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City State
Z p Phone
Aso
Contact Li se Number(Required)
Business Phone
Architect/Engineer ( )
O1/61181 Address
City State ip
Zip Phone
Contact
( )
Business Phone
Lender Ph(
)
��5/7`L �� 7— 5 Address
City -",16
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`*• ly( /Short Plat Num}berms" <
rcet Number Lot
Block Plat Number
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ate � � .�
inent Re Numbers Zone ..�---
Comp.Plan Census Tract
mberof.Dwelling Units Numberof Buildings Lot Size(Sq.Ft./Acre) De th
p Frontage
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Right Setback RearSetback
R/W Width
Square Footage ikir
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`-� Date
7 — -- I Group Type
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DEPARTMENTAL REVIEW
Approved pprov Hold
Approval
Environmental Health Application#
❑ W. 1101 College
Room 200
l TILIg 1T' PL4&rir
Planning/Zoning I I 1
❑ N.721 Jefferson (l I
2_7ingineers
N.811 Jeffersong7 r
Utilities
❑ N.811 Jefferson I I
Plan Review/Fire Prevention ybWir
I
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
❑ Fast Track/Special inspection information
Project Representative
I Phone
Address
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agenflo compile said application is true and correct.
Signature— �—I! C Z� �( 1 Date/7 2 A.
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 State Zip Phone
Contact License# Business Phone
Describe Work
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s): /
Dsh Wshr(s): / Garb Disp(s): ' Kit Sink(s): ' Lndry Tray(s): Sew Eject(s):
Urinal(s): Wtr Closet(s): /7 Lav(s): Z Shower(s): ' Tub(s): ' Bidet(s): /
lam- �.�-(,)
W Other: Type;
CC
XWaste/Grease Interceptor(s):
U-
LL Sewer Y N Septic/Health No.:
CC
W
CO Electric Water Heater(s): Drains-Roof:
2
2
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+:
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 APPLICATION
OWNER OR AGENT DATE
r
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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
0-10,000 CFM 10,000+CFM
Air Handling Units
Refrigeration Systems/ 1-100M 101-500M 501-1,000M
Heat Pumps(BTU)
1,001-1750M Over 1750M /` yo
Compressor 0-3HP 3-15HP 15-30HP 30-50HP 50+HP �p
1-5 Outlets 6+Outlets
Gas Piping
1-100,000BTU ' 10u,L00+BTU
Gas Fired Heating System
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
•
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