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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) Project Number' Owner's Name LAST FIRST MI V cA II Project ddress St barne 8, o&n1j1 350-7 6)11/ PPLE Sr- Zip Aeon •nt G . / 1 Addres I Z C�7 �, ^�� _ c. / N r City State Zip d iars 0 _ __ Contractor/Agent Add ess ,pity_ State Zip Phone ( ) Contact License Number (Required) kiege uo 25z oc Business Phone 6 ) Architect/Engineer Address City Stale Zip Phone ( ) Contact Business Phone ( I Lender Address -to.-- rCity City State Zip ti Phone 6 1 �.f��"' .tut mbef RCP -a; L`+' .`. Comm.. "„ gp ttix t c4 yi''3 +' .•., Sh�/ 'Lot » ; 'Block axk 1 `" ' `i^#{`z k s d Plat cumber S, t t°:'Ya+ ar 3-vi'p/ ,Zone. Comp PI �r.. >✓ of tBuild n s '' r a Lot Size (Sq Fj IAc4eJr ti _- si„,i'hw De' Ri _ v, JM w e. 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OMnw aMUSI as 1 Mma I I • BM tins i _14.- ;_i_ i 4 • • 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 ,�/� l ] R m Zoo hags SFc:e1Er Planning/Zoning N. 721 Jefferson Pingineera _ N -/ . 811 Jefferson/Q-'/ll p ? �'L2^G 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 co w cc 1- H LL LL 0 cc w i Z 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