1987, 01-02 Permit App: 87000063 Remodel, Plumbing Fixtures (THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE !N INK
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE .,I
Project Number el
Owner's Name LAST n FIRST MI
Project Address(Street Name&Number) Zip
55803 E____, 1 s.1- 14, 77d21 ?-..
Applicant Address
5 / t& E
City State Zip Phone
( ) 531/- - 38517
Business Phone
Contractor/Agent Address
SAO
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State I Zip Phone
( I
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
Describe Work Res. / Comm.
1._kn' E 2,biz COUPLET id at) of SasEuEiv7 ✓
Subdivision/Plat Nam t Plat Number
040S F? PLA-7--- Ob. 1
Assessor Parcel Number Lot Block Plat Number
q 23534-- 640 V 4- l
U J Pertinent File Numbers Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
I I t30 ,co
Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
VALte AT i 00 f2CUo
FLOC Pc-R •(1T =M/S• °" z
0
PL5C i2.. °`° a
2
SRC 1-IAR(3E / ' ' o
u
u.z
0
z
n
J_
5
m Number of Bedrooms
Building Technician Date Group Type
ICGrJ 1—2._-€3-7
DEPARTMENTAL REVIEW
Approved CpApproval Hold
Environmental Health Application#
❑ W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
O N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
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.
Signature Date
y 2
-
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
IProject N
Owner's Name Last First MI
Lt t LA—F---P--_ i _s.ti L-
Project Address(Street Name&Number)
g a-- �__ 1..m
State Subdivision/Plat Name )
o�c}-Nr.,..e c.— 5\--Cis-0,3 S `-- .._ t--,-.77' NO. k
Assessors Parcel if
Lot Block Plat S
,0015i4 -- _ 363fir-0,04i
> Address
Applicant
SN.1-k City I State Zip Phone
S3k4 315gs7
Business Phone
Address
Contractor
City I State Zip Phone
Contact License R Business Phone
Describe Work
Bar Sink(s): Drinking Fountain(s): Floor Drain(s): Washing Machine(s):
Dsh Wshr(s): Garb Disp(s): Kit Sink(s): Lndry Tray(s): Sew Elect(s):
Urinal(s): Wtr Closet(s): 1 Lav(s): t j Shower(s): 1 Tub(s): Bidet(s):
W Other: Type;
Ir
I- Waste/Grease Interceptor(s): /2
X
u_ Sewer Y N Septic/Health No.:
O
C
w Drains-Roof:
2
m Electric Water Heater(s):
D
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: (00 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 i APPLICATION ---- r7_ r7
Ohsi ., , -Q,1 `t _ DATE
OWNER OR AGENT