1986, 11-07 Permit App: 00014059 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 and your building plans to the Department of Building and Safety)
SHADED AHEAS AHt I -UH UtI'AH I MtN 1 AL Uat
project Numbers�.
Owner's Name LAST FIRSTsMI
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Project ddress (Street Name 8 Number) Zip
Sarum 4011 CtkwRunn Ia QQzob
Applicant
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Address
37OV 1V !4Dt rc&2
City
0775 are /)i
State
141,
Zip
ei9o27
Phone
( ) ZZ$ /307
Business Phone
( 1 Sn
Contractor/Agent
SKY r �i
5:04-14,,e_ /14/14E-5
Add
ess a/ J��
37o V / r&C-
City
27i Dieedlefrelif
State
l .a
Zip
99at7
Phone
1 ) 2_262 /307
Contact
•
License Number (Required)
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i 6 q i— Al
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Architect/Engineer
Address
City
State
Zip
Phone
(
Contact
Business Phone
l 1
Lender
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Address
City
State
Zip
Phone
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I�/ Environmental Health
LLL11J W. 1101 College
• Room 200
DEPARTMENTAL REVIEW \_
Approved
Cond.
Approval
Hold
Application N 8G - /2_4 I
Planning/Zoning
, 0 N. 721 Jefferson
Engineers �� �/ea 403 p3
N. 811 Jefferson b�
Utilities
0 N. 811 Jefferson
L
Pian Review/Fire Prevention
❑ N. 811 Jefferson
Other (SEPA/Criticai Material/etc.)
Fut Track/Special Inspection Information
Project Representative
Phone
Address
I certify that 1 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 NA /8
•• I T r L A 14
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 E. Number)
City
State
Subdivision/Plat Name
Assessors Parcel #
Lot
Block
Plat #
Applicant
Address
City I
State
Zip
Phone
Business Phone
Contractor
Address
City l
State
I
Zip
Phone
Contact
License #
Business Phone
Describe Work
Bar Sink(s):
Drinking Fountaln(s):
Floor Drain (s):
Washing Machine(s): 1
Qsh Wshr(s): `
Garb Disp(s):
Kit Sink(s): l
Lndry Tray(s):
Sew EJect(s):
Urinal(s):
Wtr Closet (s):
1,1
Lav(s): 3
Shower(s):\
Tub(s):1
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/HealthNo.:
Electric Water Heater(s): 1
1
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
q" V C MTM 'D -3 0,q . sD!L3S
Novy
AfrIztatil