1986, 1031 Permit App 00013657 Residence & Garage(THIS IS NOTA PERMIT)
'r 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
Owner's Name LAST
FIRST
MI
r"
H
Project Address (Street Name a Number)
Zip
E4c-r 14425 Evers AvE
Applicant
Address
So tie a •
b5S 6joUo r w
City
State _
Zip
Phone -
' q
YY 01) 66 / �f
Business Phona—
1 )
Contractor/Agent
Address
City
$tate
Zip
Phone
1 I
Contact
Lo-TFsses, Number(Required)
Business Phone
(NKCN � C��-
( )
Architect/Engineer
/
�) Q 6 _
Address
City J
State
Zip
Phone
Contac
Business Phone
1 )
Lender _
Address
City
State
Zip
Phone
( 1
Describe Work
Res../
Comm.
'� '%SfDEuC
WGA
Subdivision I Plat Namel Short Fat Number
Acees
I'
uJAAU
RD Ave
Assessor Parcel Number
Lot
Block
Plat Number
35& 13 - 2-�'?
C,
Z
Pertinent File Numbers
Zone
SF
Comp. Fan
Census Tract
Number of Dwelling Units
Number of Bull dings
Lot Size(Sq. Ft./Acre)
Depth
Frontage
t
iD5
SSS
Front Setback
Lett SetbackRight
Setback
{tear Setback
R/ W Width
Additional Information
Square Footage
5ct
Z
O
11401111.
O
1.z
Z
z
52.g = aAR
s
J
0
Number of Bedrooms
Building Technician,
Date
Group
Type
Gl- le. - 6(,
R-3
V00
Scale:
Date:
Revisions: Attachments:_
Show on Site Plan:
Additional Information:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Water Lines
Shorelines
Sewer Lines
Highwater Mark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Scale:
Date:
Revisions: Attachments:_
DEPARTMENTAL REVIEW
Environmental Health Application M
W. 1101 College
Room 200
0 Planning/Zoning
N. 721 Jefferson
Engineersc,
N. 811 JeVerson _
❑ 1utilities
N. 811 Jefferson
Plan Review/ Fire Prevention
❑ N. 811 Jefferson)
Other (SEPA/Critical Material/etc.)
0
Project Representative I Phone
Address
Cond.
Approval I Hold
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 �G ''� �==—Date
MECHANICAL 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 state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
OWNER OR
APPLICATION
DATE
Project H
Owner's Name
Last
First
MI
Project Address (Street Name & Number)
City
State
Subdivision l Plat Name
Asseseors Parcel if
Lot
Block
Plat if
Applicant
Address
sees
City
State
Zip
Phone
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License M
Business Phone
Describe Work
Fans
Evaporative Cooler
Hoods
Electric Furna
Miscellaneous
Dryer
Range
Gas Log
Gas Water Hir.
Solid Fuel/Wood Stove
Air Handling Units
0.10,000 CFM
10,000+ CFM
Refrigeration Systema/
Heat Pumps (BTU)
1-100M
101-500M
501-1,000M
1,001-1750M
Over 1750M
Compressor
0-3HP
3-15HP
15,30HP
30-50HP
50+HP
Gas Piping
1-5 Outlets
6+ Outlets
Gas Fired Heating System
1-100,000STU
10Q.,,AO+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
OWNER OR
APPLICATION
DATE
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
OWNER OR AGENT
APPLICATION
DATE
G7�—
Project
Owner's Name Last
First
MI
Project Address (Street Name & Number)
City
State
Subdivision) Plat Name
Assessors Parcel#
Lot
Block
Plat M
Applicant
Address
City
Stale
Zip
Phone
Business Phone
Contractor
Address
City
State
Zip
Phone
Contact
License M
&nines Phone
Describe Work
Bar Sink(s):
Drinking Fountaln(s):
Floor Draln(s):
Washing Machlne(s):
Dsh Wshr(s): /
Garb Disp(s):
Kit Sink(s):
Lndry Tray(s):
Sew Eject(s):
Urinal (s):
Wtr Closet (a): n,
!
Levis):
Shower(s):
Tub(s): /
Bidet(s):
Other: Type;
Waste/ Grease Interceptor(s):
Sewer y N Septicl Health No.:
Electric Water Heater(s):
Drains -Roof -
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
APPLICATION
DATE
G7�—
7F-