1987, 01-27 Permit App 87000520 Residence, Garage(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 AREAS ARE FOR DEPARTMENTAL USE
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O«ner'a Name
LAST
FIRST
MI
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Proled Address (Street & Number)
Zip
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Applicant
Address
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City
state
Zip
Phone
Business Phone
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COntrecter/Agent
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
056
Q 8 N (-
1
Architect/Engineer
Address
City
State
Zip
Phone
1
Conte t(
Business Phone
Lender
Address
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Slate
Zip
Phone
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1
Describe W
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Subdivision l Plat Namel Shari Plat Nurnbx
Assessor Parcel Number
Lot
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Plat Number
Pertinent Flle Numbers
Zone-
A 6Comp.
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Plan
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Census Tract
Numberaf Dxelimg Units
Number of Buildings
Lot Size (Sq. Ft /Arse)
Depth
Frontage j
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Left Setback
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Additional Information
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Number of Bedrooms,...
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DEPARTMENTAL REVIEW
I certify that I have examined this application and state that the Information contained in it and submitted
bymeormyage tocompilesaidappll it true and correct. �7
Signatu Date
Appro ed
Y
Cond.
Approval
Hold
Environmental Health Application (r� D44
W. 1101 College l
Room 200 /7
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson _. 7 /—/�/� �l� R7-,T/i%"6
Utilities
N. 811 Jefferson
Plan Review/ Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Pro)ect Representative
Phone
Address
I certify that I have examined this application and state that the Information contained in it and submitted
bymeormyage tocompilesaidappll it true and correct. �7
Signatu Date
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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
[7777
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Owner's Name Leet
Owner's
First
MI
Project Address (Street Name S Number)
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City �_
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State
L� JDi/
Subdivision/Plat Name
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Assesso'rs Parcel N
Lot
Black
Plat e
Applicant
Addfey/q n
City
State
Zip
Phone
Business Phone
Contractor
Address
City
State
Zip
Phone
License a
Business Phone
Descrlbe Work ,
Bar Sink(a):
Drinking Fountain(s): (_
Floor Drain (a):
�-
Washing Machine(s): �
Dan Wshr(s): ✓
Garb Disp(s): (:
Klt Sink(s):
'✓
Lndry Tray(s):
(
Saw Eject(s):
Urinal(s): /r1/\
l•/
Wtr Closet(s):
Lav(a):
Shower(s):
/
Tub(s):
Sidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer V N Septicl Health No.:
Electric Water Heater(s): J
Dralns-Roof:
REPAIR OR ALTERATION: Drainage, Vent, Water Piping /Treatment
y N
Lawn Sprinkler System (s), including backflow device on anyone 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
23,06
T`J
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78.137
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