1986, 07-25 Permit App: 00012338 Residencew
(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 and your building plans to the Department of Building and Safety)
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Owner's Name LAST FIRST MI
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Additional Information:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences,•Wells'
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
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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 app l tion is true - s d correct.
Signatu
Approved
Cond.
Approval
Hold
Environmental Health Application /I
,�/�
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] R m Zoo hags SFc:e1Er
Planning/Zoning
N. 721 Jefferson
Pingineera _
N -/
. 811 Jefferson/Q-'/ll p
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Utilities
N. 811 Jefferson
J
Plan Review/Fire Prevention,
N.811 Jefferson
11
Other (SEPA/CrItical Material/etc.)
Fest Track/Special Inspection Information
Protect 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 app l tion is true - s d correct.
Signatu
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject #
P ?FirMI
„ 7 // /V/G f{6Z-t 1'1 S
Owner's Name / c7 6P/77/77/
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
I State
Zip
Phone
Contact
License #
Business Phone
Describe Work
BarSink(s):
Drinking Fountain(s):
Floor Drain(s):
, Washing Machine(s): /
Dah Wshr(s): /
I
Garb Dlsp(s): I
Kit Sink(s):
/
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
Wtr Closet(s):
Lay(s): i7
/
Shower(s): r
I Tub(s):
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+:
GAS Fu rnUAtee CI
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