HomeMy WebLinkAbout3900 Depew Streeto CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office • (303) 237-8929 Fax
INSPECTION NOTICE
Inspection Type: y) 0 - P""r, l h ►'A-%jo IV
Job Address: 3 9 C d 0 cr of ./ S
Permit Number: -�d o) R o; o 3 7
[�/I e I "ce, e%
❑ No one available for inspection: Time = - AM&
Re -Inspection required: Yes No
When corrections have been made, call for re -inspection at 303-234-5933
Date: 1 a I ) Inspector:"
DO NOT REMOVE THIS NOTICE
City of Wheat Ridge
Resid. Windows/Doors PERMIT - 201801037
PERMIT NO: 201801037 ISSUED: 04/13/2018
JOB ADDRESS: 3900 Depew ST EXPIRES: 04/13/2019
JOB DESCRIPTION: Removal and replacement of like for like 7 windows. U -factor .27
*** CONTACTS ***
OWNER (303)507-9785 PIRO GEORGE M
SUB Adam Kaliner 160260 Power Home Remodeling Group
*** PARCEL INFO ***
ZONE CODE: UA / Unassigned USE: UA / Unassigned
SUBDIVISION CODE: 2412 / LAKESIDE, STEWART GARDENS, OLI BLOCK/LOT#: 0 /
*** FEE SUMMARY *** ESTIMATED PROJECT VALUATION: 9,486.32
FEES
Window Replacement 350.00
Total Valuation 0.00
Use Tax 199.21
** TOTAL ** 549.21
*** COMMENTS ***
*** CONDITIONS ***
Windows shall comply with all applicable codes, have a .32 or better U -factor and shall be
safety glazing if within a tub enclosure, less than 18 inches above the floor or within 24
inches of a vertical edge of a door.
I, by my signature, do hereby attest that the work to be performed shall comply with all accompanying approved plans and specifications,
applicable building codes, and all applicable municipal codes, policies and procedures, and that I am the legal owner or have been authorized
by the legal owner of the property and am authorized to obtain this permit and perform the work described and approved in conjunction with
this permit. I u r attest that I am legally authorized to include all entities named within this document as parties to the work to be
per
forme pecifications.
SioatTre 6f OWNER or CONTRACTOR (Circle one) Date G
I . This permit was issued based on the information provided in the permit application and accompanying )tans and specifications and is
subject to the compliance with those documents, and all applicable statutes, ordinances, regulations, policies and procedures.
2. This permit shall expire 365 days after the date of issuance regardless of activity. Requests for extension must be made in writing and
received prior to the date of expiration. An extension of no more than 180 days made be granted at the discretion of the Chief Building
Official and may be subject to a fee equal to one-half of the originalpennit fee.
3. If this permit expires, a new permit may be required to be obtained. Issuance of a new permit shall be subject to the standard
requirements, fees and procedures for approval of any new permit. Re -issuance or extension of expired permits is at the sole discretion of
the Chief Building Official and is not guaranteed.
4. No work of any manner shall be performed that shall results in a changeof the natural flow of water without prior and specific approval.
5. The permit holder shall notify the Building and Inspection Services Division in accordance with established policy of all required
inspections and shall not proceed or conceal work without written approval of such work from the Building and Inspection Services
Division.
6. The is ce or grantin f a permit shall not be construed to be a permit for, or an approval of, an violation of any provision of any
app
l ab co e or any dinance or regulation of this jurisdiction. Approval of work is subject to field inspection.
Signature of Chief Building Official Date
REQUESTS MUST BE MADE BY 11:59PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY.
City of
CWheat idge
MMUNITy DEVELOPMENT
Building & Inspection Services Division
7500 W. 29th Ave., Wheat Ridge, CO 80033
Office: 303-235-2855 * Fax: 303-237-8929
Inspection Line: 303-234-5933
Email: perm its(a)ci.wheatridge.co.us
FOR OFFICE USE ONLY
Date:
yi/�qi8
Plan/Permit #
7— of
Plan Review Fee:
Building Permit Application
*** Please complete all highlighted areas on both sides of this form. Incomplete applications
may not be processed. ***
Property Address: 5 blano'v✓ �1ai��, � ,l Q) ---
Property Owner (please print): ,_'� lc- V� 1BF 4 Phone: p'
Property Owner Email: �'aqt %, �-CJ%-)
Tenant (Commercial Projects Only)
Property Owner Mailing Address: (if different than property address)
Address
City, State, Zip:
Architect/Engineer:
Architect/Engineer E-mail:
Contractor: V2vy 2v' M>X�'
City of Wheat Ridge License #: LLW/o
Contractor E-mail Address:
For Plan Review Questions & Cbmments (please print):
CONTACT NAME (please print):
CONTACT EMAIL(p/ease print):
Sub Contractors (Must provide Wheat Ridge License No.):
Electrical: Plumbing:
W.R. City License # W.R. City License #
Phone:
PChone (U J �%y — f22?
hone:
Other City Licensed Sub: Other City Licensed Sub:
City License # City License #
Mechanical:
W.R. City License #
❑ COMMERCIAL 0 RESIDENTIAL
Description of work: For ALL projects, provide a detailed description of work to be performed,
including current use of areas, proposed uses, square footage, existing condition and proposed new
condition, appliance size and efficiency, type and amount of materials to be used, etc.
Commercial Projects Only: Occupancy Type:
Sq. Ft./LF
Amps
BTUs
Squares
Construction Type:
Gallons
Project Value: (Contract value or the cost of all materials and labor included in the entire project)
$ 17, LIIV� , 3 a.-
OWNER/CONTRACTOR SIGNATURE OF UNDERSTANDING AND AGREEMENT
I hereby certify that the setback distances proposed by this permit application are accurate and do not violate applicable ordinances, rules or
regulations of the City of Wheat Ridge or covenants, easements or restrictions of record; that all measurements shown and allegations made are
accurate; that I have read and agree to abide by all conditions printed on this application and that I assume full responsibility for compliance
with applicable City of Wheat Ridge codes and ordinances for work under any permit issued based on this application; that I am the legal owner
or have been authorized by the legal owner of the property to perform the described work and am also authorized by the legal owner of any
entity included on this application to list that entity on this application. I, the applicant for this building permit application, warrant the
truthfulness of the information provided on the application.
CIRCLE ONE: (OWNER) (CONTRACTOR) or (AUTHO ZED REPRESENTATIVE)
Signature (first and last gype). _
Printed Name:
ZONING COMMMENTS:
Reviewer:
BUILDING DEPARTMENT COMMENTS:
Reviewer:
PUBLIC WORKS COMMENTS:
Reviewer:
DEPARTMENT USE ONLY
of (OWNER) (CONTRACTOR)
DATE:
OCCUPANCY CLASSIFICATION:
CONSTRUCTION TYPE:
Building Division Valuation:
National Headquarters
2501 Seaport Drive, Chester, PA 19013
888-738-6335
WWW.POWERHRG.COM
Project Specifications
Windows: Master Basement 1 46.5"x48.0"
WINDOWS: Models SL 2700 Styles Slider Types 2 -Lite Configs None
OPTIONS: Color White / White : Grid Pattern : None I Removal Steel / Additional Details None
Windows: Master Basement 1 46.5"x48.0"
WINDOWS: Models SL 2700 Styles Slider Types 2 -Lite Configs None
OPTIONS: Color White / White : Grid Pattern : None 1 Removal Steel I Additional Details None
Windows: Gloria's Room 1 55.75"x43.0"
WINDOWS: Models SL 2700 Styles Slider Types 2-1-ite Configs None
OPTIONS: Color Cocoa / White : Grid Pattern : None / Removal Wood I Additional Details None
Windows: Playroom 1 55.75"x42.5"
WINDOWS: Models SL 2700 Styles Slider Types 2 -Lite Configs None
OPTIONS: Color Cocoa / White : Grid Pattern : None I Removal Wood I Additional Details None
Windows: Graces Room 1 56.0"x43.0"
WINDOWS: Models SL 2700 Styles Slider Types 2 -Lite Configs None
OPTIONS: Color Cocoa / White : Grid Pattern : None I Removal Wood I Additional Details None
Windows: Graces Room 1 56.0"x43.0"
WINDOWS: Models SL 2700 Styles Slider Types 2 -Lite Configs None
OPTIONS: Color Cocoa / White : Grid Pattern : None l Removal Wood 1 Additional Details None
April 12, 2018 16:34
Andrew Padilla and Sophia Medina
33-08402
April 12, 2018
National Headquarters
2501 Seaport Drive, Chester, PA 19013
888-736-6335
WWW.POWERHRG.COM
Project Specifications
Windows: Bathroom 1 18.75"x35.0"
WINDOWS: Models SL 2700 Styles Double Hung Types None Configs None
OPTIONS: Color Cocoa / White : Grid Pattern : None / Removal Wood / Additional Details None
April 12, 2018 16:34
Andrew Padilla and Sophia Medina
33-08402
April 12, 2018
Rating Council"
OWER
SL2700 DOUBLE HUNG WINDOW
VINYL FRAME DOUBLE GLAZED
FOAM FILL GRIDS LOW E /ARGON
NFRC PO#. N P -I -14.0 .
C R 100107.21.01 004883441001
ENERGY PERFORMANCE RATINGS
U -Factor (U.S. 1 1-P} Solar Heat Gain Coefficient
Visible Transmittance Condensation Resistance
e t A i CITY OF WHEAT RIDGE
Building Inspection Division
(30 Inspection line
(303) 235 -2855 Office • (303) 237 -8929 Fax
INSPECTION NOTICE
Inspection Type: L. !L— 7 �
Job Address: 3 � 90
Permit Number: eQ $ 1A `7
r
❑ No one available for inspection: Time K AM/PM
Re- Inspection required: Yes
"When corrections have been made, call for re-inspection at 303 -234 -5933
Date: ` 1 /Jo Inspector:
7
DO NOT REMOVE THIS NOTICE
.~A1i
~ CITY OF WHEAT RIDGE
~ Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office ' (303) 235-2857 Fax
INSPECTION NOTICE
Inspection Type: pmx
Job Address/Permit Number: 301)fJ
r -
.C1
❑ No one available for inspection: Time ' AMyrivi i
Re-Inspection required: No J
When corrections have heenTnade, call for re-inspection at 303-234-5933
,PP n
Date: 1` `f Inspector: AQ . L l a
J
nn MIT at=nnnvJ= rutc AUITIrX
♦~~4'
~ CITY OF WHEAT RIDGE.
' Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office ' (303) 235-2857 Fax
INSPECTION NOTICE
Inspection Type: dell.
Job Address/Permit Number: 7F9e:~,y fJeFA~w sr-, O$®.3~y
❑ No one available for inspection: Time to AM/PM
Re-Inspection required: Yes No
when corrections have been made, call for re-inspection at 303-234-5933
Date: Z%rs Inspector: /
DO NOT REMOVE THIS NOTICE
Occupancy/Type
INSPECTION LINE: (303) 234-5933
Inspections will not be made unless this card is posted on the building site
Call by 3:00 PM to receive inspection the following business day.
INSPECTOR MUST SIGN ALL SPACES PERTAINING TO THIS JOB
FOUNDATION INSPECTIONS
DATE
INSPECTOR
INITIALS
COMMENTS:
Footings/Caissons
Stemwall / (CEG) Concrete
Encased Ground
Reinforcing or Monolithic.
Weatherproof / French Drain
Sewer Service Lines
Water Service Lines
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
CONCRETE SLAB FLOOR
Electrical (Underground)
Plumbing (Underground)
Heating (Underground)
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
ROUGHS
Sheathing
Lath /Wall tie
Mid-Roof
Electrical Service
Rough Electric
Rough Plumbing
Gas Piping
Rough Mechanical
ABOVE INSPECTIONS TO BE SIGNED PRIOR TO PROCEEDING
Framing
Insulation
Drywall Screw
FINALS
Electrical
Plumbing
Mechanical
- cat pg
JAG
Roof
Building Final
Fire Department
R.O.W & Drainage
IOR T
FIN
L INSPECTIONS
S
L
IN
NE W
EK
Parking & Landscaping
.
TART AL
ROUT
G O
E
PR
O
A
"NOTE: ALL ITEMS MUST BE COMPLETED AND APPROVED BY PLANNING AND ZONING, BUILDING AND PUBLIC WORKS BEFORE A
CERTIFICATE OF OCCUPANCY IS ISSUED. FINAL INSPECTION BY THE BUILDING DIVISION DOES NOT CONSTITUTE AUTHORIZATION
OF A CERTIFICATE OF OCCUPANCY NOR PERMISSION FOR OCCUPANCY-
OCCUPANCY NOT PERMITTED UNTIL CERTIFICATE OF OCCUPANCY IS ISSUED
PROTECT THIS CARD FROM THE WEATHER
~ CITY OF WHEAT RIDGE
Building Inspection Division
(303) 234-5933 Inspection line
(303) 235-2855 Office - (303) 235-2857 Fax
INSPECTION NOTICE
Inspection Type:
Job Address/Permit Number: ~774t2 77,c2f' 4 « . >fi'r2~7
rl?,~~~;t~rt~f n
❑ No one available for inspection: Time 5','Sa AM/PM
Re-Inspection required: Yes 0-0--)-
When corrections have been made, call for re-inspection at 303-234-5933
Date: -`2/7 Inspector: Z:-L-
DO NOT REMOVE THIS NOTICE
E'
Inspections will not be made unless this card is posted on the building site
Call by 3:00 PM to receive inspection the following business day.
INSPECTOR MUST SIGN ALL SPACES PERTAINING TO THIS JOB
FOUNDATION INSPECTIONS
DATE
INSPECTOR
INITIALS
COMMENTS:
Footings/Caissons
Stemwall / (CEG) Concrete
Encased Ground
Reinforcing or Monolithic.
Weatherproof / French Drain
Sewer Service Lines
Water Service Lines
Fv N. CVNGNt It ON I IL Htl Wt MA6 CEEN SIGNED
- CONCRETE SLAB FLOOR
Electrical (Underground)
Plumbing (Underground)
Heating (Underground)-
RoUGHS
Sheathing
Lath./ Wall tie
Mid-Roof
Electrical Service
Rough Electric
Rough Plumbing
Gas Piping
Rough Mechanical
UNTIL
ABOVE INSPECTIONS TO BE SIGNED PRIOR TO PROCEEDING
Framing
Screw
i
a€
FINALS -
Electrical
Plumbing
Mechanical
Roof
Building Final
Fire Department
R.O.W & Drainage
Parking & Landscaping
START ALL ROUTING ONE WEEK PRIOR TO FINAL INSPECTIONS.
"NOTE: ALL ITEMS MUST BE COMPLETED AND APPROVED BY PLANNING AND. ZONING, BUILDING AND PUBLIC WORKS BEFORE A
CERTIFICATE OF OCCUPANCY IS ISSUED. FINAL INSPECTION BY THE BUILDING DIVISION DOES NOT CONSTITUTE AUTHORIZATION
OF A CERTIFICATE OF OCCUPANCY NOR PERMISSION FOR OCCUPANCY.
UCCUPANCY NOT PERMITTED UNTIL CERTIFICATE OF OCCUPANCY IS ISSUED
PROTECT THIS CARD FROM THE WEATHER
p Occupancy/Type
INSPECTION LINE: (303) 234-5933
, City of Wheat Ridge
Residential Mechanic PERMIT - 081364
PERMIT NO: 081364 ISSUED: 11/20/2008
JOB ADDRESS: 3900 DEPEW ST EXPIRES: 05/19/2009
DESCRIPTION: Replace 120,000 btu furnace
CONTACTS _
owner 303/420-4941 George Piro
sub 303/452-1420 JOHN W. WHEELER 01-8793 Wheeler's Plumbing Heating.& C
PARCEL INFO
ZONE CODE: UA USE: UA
SUBDIVISION: 0435 BLOCK/LOT#: 0/
FEE SUMMARY ESTIMATED PROJECT VALUATION: 7,000.00
FEES
Permit Fee 181.10 c(~111
Total Valuation .00
Use Tax 126.00
TOTAL 307.10
Conditions:
Must comply w/ 2003 IRC & 2005 NEC.
Subject to field inspections.
I hereby certify that the setback distances proposed by this permit application are accurate, and do not violate applicable
ordinances, rules or regulations of the City of Wheat Ridge or covenants, easements or restrictions of record; that all
measurements shown, and allegations made are accurate; that I have read and agree to abide by all conditions printed on this
application and that I assume full responsibility for compliance with the Wheat Ridge Building Code (I.B.C) and all other
app able at Ridge Ordin ces,for work under this permit. Plans subject to field inspection.
ign re of contractor/owner data _
1 his permit was issued in accordance with the provisions set forth in your application. and is subject to the laws of the
State of Colorado and to the Zoning Regulations and Building Codes of Wheat Ridge, Colorado or any other applicable
ordinances of the City.
2. This permit shall expire 180 days from the issue date. Requests for an extension must be received prior to. expiration
date. An extension may be granted at the discretion of the Building Official.
3. If this permit expires, a new permit may be acquired for a fee of one-half the amount normally required, provided no
changes have been or will be made in the original plans and specifications and any suspension or abandonment has not
exceeded one (1) year. If changes have been or if suspension or abandonment exceeds one (1) year, full fees shall'
be paid for a new permit.
4. No work of any manner shall be done that will change the natural flow of water causing a drainage problem.
5. Contractor shall notify the Building Inspector twenty-four (24) hours in advance for all inspections and shall receive
written approval on inspection card before proceeding with successive phases of the job.
6. The issuance of a permit or the approval of drawings and specifications shall not be construed to be a permit for, nor
an approval of, any violation of the provisions of the building codes or any other ordinance, law, rule or regulation.
All plan review is s .ec o field inspections. -
Zv fl~
Signature of Chief B lot Official dat
INSPECTION. RE EST LINE: .(303)234-5933 BUILDING OFFICE: (303)235-2855
REQUESTSMUST -BE MADE BY-3PM ANY BUSINESS DAY FOR.INSPECTION . THE FOLLOWINGS BUSINESS DAY.:
OF wHE?>,p/ City of Wheat Ridge Building Division Date: :•~~j~`
7500 W. 29th Ave., Wheat Ridge, CO 80033
Office: 303-235-2855 * Fax: 303-235-2857 Plan
c p Inspection Line: 303-234-5933 Permit#: F~/nybl+
ptORPp
Building Permit Application
Property Address: 3 y00 016- 7
Property Owner (please print): 4a,e / Phone:
Mailing Address: (if different than property address)
Address:
City, State,
Contractor:
P'4 0
Contractor License
Phone:
Sub Contractors:
Electrical City License Plumbing City License Mechanical City License
Company: Company Company:
Exp. Date: Exp. Date: Exp. Date:
Approval: Approval: Approval:
Use of space (description): Construction Value:
Description pat of work: p (as calculated per the Building Valuation Data sheet)
a4tz ~(~2 NQ GG Plan Review (due at time of submittal): $
/(rte `c 93~
Gallons Amps
Sq. Ft./L.Ft added: Squares BTU'S/
OWNER/CONTRACTOR SIGNATURE OF UNDERSTANDING AND AGREEMENT
I hereby certify that the setback distances proposed by this permit application are accurate, and do not violate applicable ordinances,
rules or regulations of the City of Wheat Ridge or covenants, easements or restrictions of record; that all measurements shown, and
allegations made are accurate; that I have read and agree to abide by all conditions printed on this application and that I assume full
responsibility for compliance with the Wheat Ridge Building Code (I.B.C) and all other applicable Wheat Ridge Ordinances, for work
under this permit. Plans subject to field inspection.
CIRLCE ONE:: (IGl*R+ER,) (CONTRACTOR) or PERSONAL REPRESENT TIVE of (OWNER) (CONTRATOR)
PRINT NAME: •Jt7/VAl 0- L~P IE4L 0- SIGNATURE: ~ Date://
ZONING COMMENTS
Zoning:
Reviewer:
PUBLIC WORKS COMMENTS
Reviewer:
BUILDING DEPARTMENT COMMENTS.
Reviewer:
FIRE DEPARTMENT:: ❑ approved w/ comments ❑ disapproved ❑ no review required Bldg Valuation:
OCCUPANCY:
" , City of Wheat Ridge
./y
Residential Roofing PERMIT - 081297
PERMIT NO: 081297 ISSUED: 11/05/2008
JOB ADDRESS: 3900 DEPEW ST EXPIRES: 05/04/2009
DESCRIPTION: Reroof w/ Monier life tile 49 sqs
CONTACTS
owner 303/420-4941 George Piro
go 303/825-5273 08-0138 Colorado Roofing & Exteriors
PARCEL INFO
ZONE CODE: UA
SUBDIVISION: 0435
USE: UA
BLOCK/LOT#: 0/
FEE SUMMARY ESTIMATED PROJECT VALUATION: 23,020.00
FEES
Permit Fee 490.50
Total Valuation
Use Tax 414.36
TOTAL 904.86
Conditions:
6 nail installation & mid-roof inspection required. Board sheeting spaced more
then a 1/4 of an inch apart requires plywood overlay on entire roof
I hereby certify that the setback distances proposed by this permit application are accurate, and do not violate applicable
ordinances, rules or regulations of the City of Wheat Ridge or covenants, easements or restrictions of record; that all
measurements shown, and allegations made are accurate; that I have read and agree to abide by all conditions printed on this
application and that I assume full responsibility for compliance with the Wheat Ridge Building Code (I.B.C) and all other
applicable Wheat Ridge Ordinances, for work under this permit. Plans subject to field inspection.
Signature of contractor/owner date
1. This permit was issued in accordance with the provisions set forth in your application and is subject to the laws of the
State of Colorado and to the Zoning Regulations and Building Codes of Wheat Ridge, Colorado or any other applicable
ordinances of the City.
2. This permit shall expire 180 days from the issue date. Requests for an extension must be received prior to expiration.
date. An extension may be granted at the discretion of the Building Official.
3. If this permit expires, a new permit may be acquired for a fee of one-half the amount normally required, provided no
changes have been or will be made in the original plans and specifications and any suspension or abandonment has not
exceeded one (1) year. If changes have been or if suspension or abandonment exceeds one (1) year, full fees shall
be paid for a new permit.
4. No work of any manner shall be done that will change the natural flow of water causing a drainage problem.
5. Contractor shall notify the Building Inspector twenty-four (24) hours in advance for all inspections and shall receive
written approval on inspection card before proceeding with successive phases. ofthe job.
6. The issuance of a permit or the approval of drawings and specifications shall not be construed to be a permit for, nor
an approval of, Xviat° of the provisions of the building codes or any other ordinance, law, rule or regulation.
All plan review field inspections.
Signature of Chief ial data
INSPECTION REQUEST LINE: (303)234-5933 BUILDING OFFICE: (303)235-2855
REQUESTS MUST BE MADE BY 3PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY.
~pFWHEgrR/ City of Wheat Ridge Building Division
7500 W. 29th Ave., Wheat Ridge, CO 80033
Office: 303-235-2855 * Fax: 303-235-2857
o p Inspection Line: 303-234-5933
Ot ORPO
Building Permit Application
Property Address: ~Q&70 `a{~eAg 5a-
Property Owner (please print):
Date: 1
TV)
Plan
Permit
Phone:
Mailing Address: (if different than property address)
Address:
City, State,
Contractor:
Contractor License Phone: 303 &Aj ~Z 73
Sub Contractors:
Electrical City License Plumbing City License Mechanical City License
Company: Company Company:
Exp. Date: Exp. Date: Exp. Date:
Approval: Approval: Approval:
Use of space (description): Construction Value: $ 23 t-) 2-0
Description of work: (as calculated per the Building valuation Data sheet)
&14 le ~i(, P- Plan Review (due at time of submittal): $
Sq. Ft./L.Ft added: Squares 17 BTU's Gallons Amps
OWNERICONTRACTOR SIGNATURE OF UNDERSTANDING AND AGREEMENT
I hereby certify that the setback distances proposed by this permit application are accurate, and do not violate applicable ordinances,
rules or regulations of the City of Wheat Ridge or covenants, easements or restrictions of record; that all measurements shown, and
allegations made are accurate; that I have read and agree to abide by all conditions printed on this application and that I assume full
responsibility for compliance with the Wheat Ridge Building Code (I.B.C) and all other applicable Wheat Ridge Ordinances, for work
under this permit. Plans subject to field inspection.
CIRLCE ONE:: c(OWNER) ~(CONTRACTOR) or PERSONAL REPRESENTATIVE of (OWNER) (CONTRATOR)
PRINT NAME: (~Yt cs.~rl I"Ilc w~ SIGNATURE: Date: l~
DEPARTMENT USE ONLY
ZONING COMMENTS:
Zoning:.
Reviewer.
PUBLIC WORKS COMMENTS:
Reviewer:
BUILDING' DEPARTMENT COMMENTS: OCCUPANCY:
Reviewer:
FIRE DEPARTMENT:: ❑ approved w/ comments ❑ disapproved ❑ no review required Bldg Valuation: $
-- ,_..---,.-...~--
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132641
FLOOR APT, NO,
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CONDITION TO BE CORRECTEO AS SHOW>I BELOW CREATES AN IMMEDIATE HAZARO, TIllS EQUIPMENT MUST NOT BE PUT BACK IN
SERVICE UNTIL REPAIRS AND A TIlOROUGH INSPECTION HAVE BEEN MADE BY A QUAUFIED CONTRACTOR. CONTACT YOUR LOCAL
BUILDING DEPARTMENT FOR COOE ANO PERMIT REQUIREMENTS p.RlORTO PERFORMING REPAIR WORK.
SPECIFY
ACTION TAKEN
NO SHUT OFF
APPLIANCE OFF
BOTH APPL & METER OFF
METER SHUT OFF
HAZARD
SHIP OF OCCUPANT TO CUSTOMER
,;,:",;C~t-~r,;"",{l':,............."",""~,,
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