1987, 01-07 Permit App 87000033 Addition(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)
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Owner's Name LASTFIRST MI
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Project Address (Street Name & Number) Zip
Applicant
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Address
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City
�/42 k
State
GL.
Zip
9.:2_ l
Phone
(5Z)?) 7 —' e/LzigaZ
Business Phone
( 7) 5-'35-3o/c-
Contractor/Agent
_
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( 1
Lender
Address
City
State
I Zip
Phone
(
Describe Work •
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Res.
Comm.
Subdivision/Plat Name/Short Plat Number
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Assessor Parcel Number
Lot
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
1
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
(47
Frontage 1
I I 0
Front Setback
Left Setback
Right Setback
Rear Setback
R/ W Width
Additional Information
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1 BUILDING INFORMATION
Square Footage
'ter = 3- 28 = loot
Fmk: 2-46'
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11544-10-
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Number of Bedrooms
Building Technician
Date
Group
Type -
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health Application #
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W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
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Plan Revlew/Fire Prevention/
N. 811 Jefferson
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Other (SEPA/Critical Material/etc.)
Fast Track/Speclal 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 compileid application is true and correct.
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Signature
Date C`"�
Show onSite Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right oYWay Width(w)
Names of
Fronting Street
Flanking Street
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
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8ignage
Shorelines
HighwmteryNork
Legal Description
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PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE 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 I
State
Zip
Phone
Business Phone
Contractor
Address
City
I State
Zip
Phone
Contact
License #
Business Phone
Describe Work
BarSink(s):
Drinking Fountaln(s):
Floor Drain(s):
Washing Machine(s):
Dsh Wshr(s):
Garb Disp(s):
Klt Sink(s):
Lndry Tray(s):
Sew Eject(s):
Urinal(s):
WtrCloset(s):
Lav(s): 2.
Shower(s):
Tub(s): z_
Bidet(s):
Other: Type;
Waste/Grease Interceptor(s):
Sewer Y N Septic/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+:
6 X4 _ 2�-
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 DATE
APPLICATION