1986, 09-28 Permit App: 00013323 Residence(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original arfd4your building plans to the Department of Building and Safety)
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Zip
Phone
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Business Phone
Contractor/Agent
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Phone
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^'cense Number (Required) 3 — 9 — g7
Address
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Contact
Business Phone
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Additional Information:
Lot Dimensions
Existing
Landscaping
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Structures
Proposed Improvements
Drainage Pian
Hydrants
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StructureSetbacks
Topography
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Easements
Septic System (s)
Lighting
Signage
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Water Lines
Sewer Lines
Shorelines
Highwater Mark
Fences, Wells
Driveway(s)
Right Way
of Width(s)
Names of
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Fronting Street
Flanking Street
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Legal Description
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DEPARTMENTAL REVIEW
1 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
Cond. Approvalp
Hold
Environmental Health Application 0
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
N. 811 Q San
N. 811eeJeff ferson
LT
_
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Materlai/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
1 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
1
•
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 i
Project #
Owner's Name Last First MI
1` L oL) 1"
Project Address (Street Name & Number)
City
State
Subdivision/Plat Name
Assessors Parcel It
Lot
Block
Plat #
Applicant
Address
City I
State
Zip
Phone
Business Phone
Contractor
Address
City
I State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountain(s):
Floor Drain (s):
Washing Machine(s): 1
Dsh Wshr(s): 1
Garb Disp(s):
Kit Sink(s): `
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
WtrCloset (s):
Lav(s):
Shower(s): 1
Tub(s): 1.,
Bidet(s):
Other: Type;
i
Waste/Grease Interceptor(s):
; Sewer Y N Septic/Health No.:
I
I Electric Water Heater(s): I
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:
(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 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
Address
City
State
Zip
Phone
Contact
License #
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furnace/Ducts
1
Miscellaneous
16,
Dryer
Range
Gas Log
Gas Water Htr.
Solid Fuel/Wood Stove
F/19 INis a- I
Air Handling Units
0-10,000CFM
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
15-3OHP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000BTU
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