1986, 10-09 Permit App: 00013669 Residence (THIS IS NOT A 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 AREAS ARE FOR DEPARTMENTAL USE Project Number f j_ q(
Owner's Name LAST FIRST MI ��o
Project Address(Street Name&Number) Zip
ApplicantAddress
KgptL, 0_Ons aa)( 3
Ths
State Zip Phone
arc\ ovtcs C�I� 9940x-7 ! ) qa2- 3q0 y
Business Phone
( )
Contractor/Agent Address
0 VA
City State Zip Phone
Contact License Number(Required) Business Phone
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
Lender Address
City State Zip Phone
! )
Describe Work
R Comm.
Subdivision/Plat Name/Short Plat Number /
Assessor Parcel Number Lot Block Plat Number
1. P4- e•C t7
Pertinent File Numbers Zone
A_ n, Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information
Square Footage
a
2
cc
0
u_
m Number of Bedrooms
Building Technician Date Grou T
PType
DEPARTMENTAL REVIEW
Approved Approval Hold
/ Approval
Environmental Health Application I
4 W. 1101 College
Room 200
yea-011--
."stir
Planning/Zoning
❑ N.721 Jefferson
JEngineers m 9
N.811 Jefferson &(A-.-Y?
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson(7) C
Other(SEPA/Critical Material/etc.)
❑ Fast Track/Special Inspection information
Project Representative Phone
Address
I 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.
(101/7,
Signature Date
r r
• MECHANICAL PERMIT APPLICATION WORKSHEET
RLEASE 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. , i, 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
Compressor 0-3HP 3-15HP 15-30HP 30-50HP 50+HP
1-5 Outlets 6+Outlets
Gas Piping
Gas Fired Heating System 1-100,000BTU — 10v,:.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
f \
•
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 I State Zip Phone
Contact License# Business Phone
Describe Work
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): t Washing Machine(s):
Dsh Wshr(s): t Garb Disp(s): Kit Sink(s): Lndry Tray(s): Sew Eject(s):
Urinal(s): WtrCloset(s): Lav(s): '2) Shower(s): ` Tub(s): Bidet(s):
rn Other: Type;
CC
t- Waste/Grease Interceptor(s):
X
U
LL' Sewer Y N Septic/Health No.:
0
CC
W
Oa Electric Water Heater(s): Drains-Roof:
Z 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 APPLICATION
OWNER OR AGENT DATE
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