1987, 01-30 Permit App: 87000291 Residence I '.
(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET 14413
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
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Pr Number—_87_24/
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Owner's Name LAST FIRST MI
Project Address(Street Name&Number) Zip
L _ i4S3c (404 c�
Applicant Address
City State I Zip Phone
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Business Phone
1 i
Contractor/Agent Address
Koss 0A—O _ ____ _ c - I i LN,co Ls, kr
City State Zip Phone
SrL.,j2_, Li./14- a01 ( 1 kf((—to i3
Contact License Number iRequired) Business Phone i•
_
Architect/Engineer .___'.-_,�- ���' Address
NIA --
City ( State I Zip Phone
I L l
Contact Business Phone
Lender — Address
City State Zip Phone
A 1 I 3�.L7 )_
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Describe W Res. Comm.
‘.7
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number 2SG26 350-7 Lot Block ( Piat Number
' Pertinent File Numbers Zone }� Comp.Plan Census Tract
r OC-
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
I=-I-1
Front Setback Left Setback Right Setgack/ / Rear Setback R/W Width
l LJ i.r
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Additional Information Square Footage
l-f6-A-7Cg— z VbQ-1 U r)5
0
cc
0
LL -
z
0
z
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5
m Number of Bedrooms
Building Technician Date (� Group Type
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******************************************************************************
* INFCRMATICN wCRKSHEET
******************************************************************************
* GENERAL INFORMATION *
* PARCEL NUMBER :
* *
* STRT ADDRESS :_
* --- *
* CITY/STATE /ZIP :
* *
* SUBDIVISICN :
* BLCCK :__ LILT :__ ZONE:____ DISTRICT#: *
* LOT AREA:__ F/A :__ - WIDTH : DEPTH : R/W:
* *
* # OF BLDGS :__ _ # CF DWELLINGS:
*
OWNER : - PHONE:____-____- *
* MAILING ADDRESS : _ *
*
* CITY/STATE/ZIP :
* CONTACT : PHCNE:-__-_ -
*
******************************************************************************
**************************************.****************************************
* PLUMBING INFORMATION *
* CONTR LIC#:___
* *
* CONTRACTOR : ___--- PHCNE: - - +
* FIRM NAME :
* *
*******************4**********************************************************
* MECHANICAL INFORt.tATICN *
* CONTR
*
* CONTRACTOR : PHCNE:
* FIRM NAME :
* ELECTRIC:_ GAS : OIL: COAL:___ W000: SOLAR :___ HEAT PUMP:__ *
* *
******************************************************************************
**********************************#*` rni****************************************3
MECHANICAL FEES PLUMBING FEES
ITEM DESCRIPTION NLMBER CF ITEM DESCRIPTION NUMBER OF
PROCESSING FEE YES OR NG PROCESSING FEE YES OR NC
DUCTWORK SYSTEM _ _ TOILETS ./.
_ _
wOCCSTCVE/ INSERT SINKS _ _
GAS WATER HEATERSHOWERS ___I___
GAS H.TG EQUIP<10C,000>BTU _ _ BATH TUBS __ I_
GAS hTG EQUIP+100,000 BTU _ _ KITCHEN SINKS __1___
GAS PIPING - # OF UNITS __L___ DISH WASHERS __I _
HEATPUMP 1-100M ETU _ GARBAGE DISPCSAL __I _
HEATPUMP 101-500P BTU _____ CLOTHES WASHER
HEATPUMP 501-1, 000M BTU _____ UTILITY SINKS __
HEATPUMP 1 ,001-1750N BTU ELECTRIC WATER HEATERS _ __
HEATPUMP +1 ,750M BTU _ FLOOR DRAINS __�_
REFRIG 1-100M BTU _____ FLOCR SINKS _
REFRIG 101-500M BTU ______ BAR SINKS -
REFRIG 501-1,000M BTU __ _ ROOF GRAINS __
kEFRIG 1 ,001-1 .750M BTU _____ LAWN SPRINKLER _____
REI-RIG +1 , 750M BTU _ SEWAGE EJECTOR _
AIR CONDITIONER 0-3 HP ____ WATER SOFTENER _ __
AIR CGNG IT iCNER 3-15 HP ___..___ URNAL
------
AIR CCNDITICNER 15-3C HP _ DRINKING FOUNTIAN _____
AIR CCNDITICNER 30-50 HP _�_� /2
AIR CONDI TICKER +50 HP _
VENTILATING FANS _
EVAPORATIVE COOLERS ______
HOODS
CLOTF-ES DRYER _____
RANGE _
GAS LOG _ _
UNLISTED GAS APPLIANCE _4___
AIR HANDLER 1-10000 CFM _ __
AIR HANDLER 10000+ CFM ______
DEPARTMENTAL REVIEW
Approved Cond.
[� Approval /
Environmental Health Application# 6d--�=—V O' 0 y�� /r
W. 1101 College V
Room 200
Planning/Zoning
❑ N.721 Jefferson
0*,fi'
Engineers
N.811 Jefferson S'Ji/to¢ O 3,2-
Utilities I
❑ N.811 Jefferson
-.,:/2,e,t/t;
Plan Review/Fire Prevention
❑ N.811 Jefferson
•
Other(SEPA/Critical Material/etc.)
O .
❑ 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.
Signaturra1 \A-%
Date I —'1 "+o1
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