HomeMy WebLinkAbout19-2860 1854 Elizabeth Blvd bldg 14 building permit app City of Twin Falls
Building Department
203 Main Ave. E. Phone: 208-735-7238
0 P.O. Box 1907 Fax: 208-736-2256
<F SfRviNG Q� Twin Falls, ID 83303-1907 www.tfid.org
New or Addition Commercial Building Permit Application
Type of Permit Requested
❑New Complete Building ✓❑Mi&Fan*(3 or more units) New Sq. Ft. 5464
❑Addition
❑Commercial Site Plan-Buildable Lot Exist.Sq. Ft.
❑Shell Building-No Interior walls(no occupancy)
❑Shell Building-with interior walls(no occupancy) Total Cubic Feet ( Fire District Only")
PROJECT INFORMATION Special Use Permit#:
Project Address: 1854 Elizabeth Blvd, Buildings 12, 13& 14 Subdivision: Snyder Tract
Business/Tenant using space: Lot/Block/ Lot 6 A, B, &C
Parcel#:
Zoning District R-4 PUD/ZDA Name:
PROPERTY OWNER INFORMATION CONTRACTOR INFORMATION
Business name: Elizabeth Properties LLC Business Name: Weathervane Homes
Contact name: Gerald Martens Address:
Address: 621 N. College Rd, Suite 100 City, State,Zip:
City, State,Zip: Twin Falls, ID 83301 Phone:
Phone: 208-734-4888 Fax:
Fax: 208-734-6049 Email:
Email: gmartens@ehminc.com State Registration#
&Expiration Date:
ARCHITECT INFORMATION ENGINEER INFORMATION
Business Name: Business Name:
Contact Name: Contact Name:
Address: Address:
City,State,Zip: City, State,Zip:
Phone: Phone:
Fax: Fax:
Email: Email:
ADDITIONAL CONTACTS:Project Manager, other designers,contacts,etc
Business Name: Stockton Property Management LLC Business Name:
Contact Name: Curtis Stockton Contact Name:
Address: 621 N. College Rd Suite 102 Address:
City,State,Zip: Twin Falls, ID 83301 City, State,Zip:
Phone: 208-918-7540 Phone:
Fax: Fax:
Email: cestockton@gmail.com Email:
1. Project Description: 4 Plex units
2. Project Value: $ 365,000
A. Project Value is used to calculate fees for the building permit. Project Value is the total value of the construction
work for which the permit is issued,including overhead and profit as well as finish work,painting,roofing,
electrical,plumbing,heating,air conditioning,elevators,fire extinguishing systems,other permanent equipment,
and owner supplied items. Project value excludes the value of the land.
I certify that the value&scope of work provided above are the most accurate available at this time:
(applicant) Gerald Martens 7/30/2019
Print Name Signature Date
3. Planning&Zoning Info A. Land Use Zone: R-4 B. Parking Spaces 2.5 per unit
C. Req'd Landscaping provided SF#: per site plan D. Alcohol License?Yes or ONO
o E. Special Use permit required?Yes Oor NO O F. Building Height:
4. Engineering Info A. Flood Plain?—ayes (�no B. Site Drainage Area w/Calcs
B. Water Tap Size C. Sewer Tap Size
5. Building&Fire Info
***Attach a site-specific letter from the engineering department or other public water provider stating fire flow at hydrants.
Include static pressure if fire sprinklers are to be installed.***
A. Fire Flow:
B. Static Pressure:
C. Is there a fire alarm system? Eyes ❑No ❑Partial
D. Is the building fully fire sprinkled? Eyes ONO ❑Partial
If yes,will the sprinklers be used for: Allowable Area Increase? ❑Yes ✓❑No
Story Increase? ❑Yes ✓❑No
Fire-resistive Substitution? ❑Yes F-,—]No
If partially sprinklered,where?
E. Are there any classified areas per NFPA? ❑ Yes ✓❑No(if yes,please show on plans and explain classification)
F. Proposed Use G. Occupancy Class(s): R-2
H. Construction Type: V-B I. Building Height: 28'
J. Number of Stories: 2
***FYI...Fire sprinklers plans and Elevators plans to be submitted to the State for review.***
***NOTICE***
All permits expire 180 days from the date of their issuance or the date of the last inspection. Expired permits will require
reactivation at such time that the responsible party decides to complete the project. Reactivation fees will be required on all
permits. Furthermore,any application that has not been issued or picked up after 180 days will become null and void.
***New commercial projects/and or additions with all the required submittals are not expected to exceed 2-3 weeks for the
initial review,but could take longer depending on needed revisions or current workload. Please let the Building Department
know if there are any unusual time constraints and we will work with you to move your project forward as quickly as possible.
Please keep in mind that any missing information from the below checklist will cause delays in the review&processing of the
permit application.
General Requirements for all plan submittals (to be FOR CONSTRUCTION):
Digital Plans required for submittal: Save plans "to scale" (actual size pages will be printed) as a PDF &combine
together. We prefer plans to be saved directly from CAD (instead of scanned) so the file is "intelligent". Digital signatures
OK. *Please call front building desk 208-735-7238 to coordinate best way to transfer files for application.
Small files email to.buildinqfaxC@tfid.org
(New & Addition) Commercial/Non-Residential/Multi-Family Plan Review Checklist
Notice to applicants: This checklist is designed to provide the basic information needed to allow the various agencies with
the City to complete a plan review of the proposed project. The basic requirements outlined below may not be all inclusive.
CONSTRUCTION PLANS (NEW Construction, Additions & Remodels)
***(DESIGN PROFESSIONAL TO GO THROUGH LIST AND CHECK OFF THAT ALL REQUIREMENTS HAVE BEEN PROVIDED
ON PLANS.) ***MISSING ITEMS BELOW WILL DELAY ISSUANCE OF THE BUILDING PERMIT***
0 Civil Site Plan(This is REQUIRED separate from the architectural site plan)To include:
0 Scale and format to be standard scale at between 1:10 to 1:60 scale;
0 Digital paper size typically 2436,but other sizes may be approved on a case by case basis.
❑ Legal description and/or record of survey for the property and a vicinity map w/north arrow.
r❑ Property lines and lot dimensions, including minimum building setbacks from property lines to be clearly shown on site plan. We
ommend using a legend to clearly designate the different line types.
0 Right-of-way details including access,easements, utilities,drainage,wastewater, right of way to be dedicated;
0 Right-of-way improvements,both existing and proposed;along with right of way dedication according to the master transp. plan.
s❑Accessible route of travel from parking spaces to the building entrance and connecting to the public right-of-way.
0 Fire department all weather access(access must be 20 feet wide with a 75,000 pound load capacity and reach within 150 feet of
any/or all portions of the exterior walls of the building(s).
0 Fire hydrants within 1000 feet&fire line location must be shown on the site plan;a water model may be required to determine fire
flow. Identify existing and new.
0 Grading plan including finished floor elevations,accessible route and top of curb elevations.
0 Utility services—Number of water services including size and location;sewer location and proposed connection to the main;
irrigation service size and location,grease interceptor(including a detailed design)for all food service occupancies;
0 Parking lot layout,including fully dimensioned space&aisle layout,detailed handicapped parking spaces&accessible route from
right of way to entrance.
0 Storm Drainage—Show on site retention design,and or waterways.
0 Storm Drainage Calculations—To be designed&stamped by an Idaho Registered Civil Engineer or Landscape Architect.
❑ Geotechnical report—when building within 100'of canyon rim. 50'closest allowed to canyon rim.
❑ Water tap size needed(or well permit,if applicable)&location shown on plans.
❑ Sewer lateral location,&sewer tap size.
r❑ All public water or sewer mains to have a 15'easement min.
0 Proposed and existing curb,gutter,sidewalk,and driveway approaches.
❑ Flood Plain indicated if within 100 year or less flood zone.
0 Architectural Site Plan(This is REQUIRED in addition to the civil site plan)To include:
El Scale typically 1/8"per foot for large projects and'/4"per foot for smaller ones. Other sizes allowed on a case by case basis.
El Location of new and existing structures and distance between them.
El Show any areas used for the storage or use of materials regulated by the IFC;
0 Show required square footage of Landscaping—Including all types and locations of landscape areas showing berms,trees,bushes,
fencing,and retaining walls.
0 Exterior lighting fixtures showing lumens per foot(City Code 10-11-4)
El Show all setbacks and easements including location of proposed building pad.
El Show trash enclosure/mechanical equipment areas with method of screening,loading docks,storage areas,&pedestrian ways.
0 Location of new and existing structures with fully dimensioned measurements to property lines&other structures;
0 Parking lot design—Including fully dimensioned spaces,isles,and landscape islands per city code 10-10.
0 If applicable...required improvements per SUP, PUD,ZDA,or HPC conditions.
1771 Drive thru isle with extra escape lane(if applicable).
❑ CODE/PLAN ANALYSIS—Required information is detailed on the example code Analysis form within the application. Example plans
analysis to only be used as a guide,and not the actual plans analysis.
-1 ComCheck Energy Analysis—Prepared by an Idaho licensed architect or engineer. (Include envelope,interior and exterior lighting&
mechanical compliance worksheets)Can be prescriptive or performance approach.
0 Foundation Plan—(stamped by the Idaho licensed Design Professional performing the structural calculations)
Include all required structural steel reinforcing,tie downs and special inspection criteria.
0 Floor Plan—Including all exit schemes,travel distances,exterior wall openings,door swings,use designations,exit signage, location of fire
extinguishers,high pile storage areas,and square footages. For tenant improvements or remodels, include floor plan of the entire building.
Indicate the existing occupancies of tenant spaces in contact with new tenant improvement or remodel.
0 Elevations—North, South, East,West(show building height dimensions) *Indicate street side elevations for address numbers.*
r❑ Building Sections and Details—Full exterior wall section from foundation to roof, interior wall section,&stair section. Including the room
finishes for ceilings,walls and floors. Also,include schedules for all windows and doors, indicating the type,size,safety glazing,and door
hardware. Provide full UL or GA Listings and details for fire separations(not just the listing number). Provide fire stop material
specifications along with U.L.design details. Include sections of all walls showing height and how to be built.Also show any grid ceilings or
storage above ceilings and framing details.
0 Structural Plans(stamped by the Design Professional performing the structural calculations)—Roof framing plan,floor framing plan,
header and beam schedules,strap locations,structural details,shear walls,shear wall schedule,lintels, lintel schedule and all other
structural information as indicated in the calculations or required by the Building Official.Any special details(i.e.,storage above restrooms)
0 Foundation,Structural&Shear Engineering Calculations—Calculations must be stamped and signed by an Idaho Registered Engineer
or Architect. (Exception: prescriptive parameters of section 2308 of the IBC 2012,and design will be required). Required for:
0 All new construction&additions.
❑ Metal buildings. Drawings and structural calc's will be required for all pre-fabricated metal buildings, including concrete footing details.
Calculations must be stamped and signed by an Idaho Registered Engineer or Architect.
❑ Modular buildings. Engineering calculations will be required for the foundation design for all modular buildings. Calculations must be
stamped and signed by an Idaho Engineer or Architect. (Modular buildings are required to have Idaho Division of Safety approval.)
o❑ Conservation Elements—Insulation R-values,glazing U-Factors,glazing solar heat gain coefficient(SHGC)value, rough opening sizes.
,r❑ Electrical Plans—Exit signage,switching diagrams, lighting schedule with fixture,bulb and ballast type, number of bulbs per fixture,and
fixture wattage;exterior lighting bulb and ballast type,and type of control. Location of exit signage and emergency lighting shall coordinate
with the floor plan or the reflected ceiling plan.(list and give details/boundaries of any classified areas per NFPA&NEC)
0 Mechanical Plans—Equipment schedule listing the make and model of the equipment and other information pertinent to compliance with
IECC;duct insulation R-values,mechanical system control schematic load calculations. Information regarding all fire rated penetrations,
smoke dampers,fire dampers,etc. Ventilation design&calculations. Mechanical engineering plans may be required on certain projects.
(Provide calculations on plans if using either natural instead or mechanical ventilation) See: IBC section 1203&IMC section 402&403
0 Plumbinq Plans—Plumbing plan,isometrics,grease/sand interceptor details,and calculations to determine actual interceptor sizing
according to the requirements in the Idaho State/Uniform Plumbing Code. Be sure to include the sewer connection location,type and
location of reduced pressure backflow devices(s),gas line piping materials and calculations,water line piping layout and materials,and
drain/waste/vent piping layout and materials.
Additional Handicap Accessibility Information—Define accessibility access features for new construction per the current International
Building Code,ANSI A117.1. For remodeling and tenant improvements,the area of improvement shall comply with the access
requirements in the International Existing Building Code. An accessible route of travel will be required to the remodeled/improved area.
❑ Fire Department Requirements.—Location and type of fire extinguishers,fire alarms, hoods, pull stations for hood,sprinkler system,riser
rooms,etc.
❑ MSDS Sheets—Completed Material Safety Data Sheets and the location and quantities of storage of such materials shall be provided with
the building permit submittal where any chemicals or hazardous materials may be present.
❑ Provide statement of special inspections per IBC 1704.1.1. A final report documenting required special inspections and correction of any
discrepancies noted in the inspections shall be submitted at a point in time agreed upon by the permit applicant and the building official prior
to the start of work.
0 Completed Waste Water Survey(see survey in this application)
0 Completed Sewer Capacity Fee Worksheet(see the form in this packet)
❑ HEALTH DISTRICT APPROVAL IS REQUIRED FOR ALL BUILDINGS WHERE FOOD IS BEING PREPARED. A LETTER OF
APPROVAL MUST BE SUBMITTED TO THE BUILDING DEPARTMENT PRIOR TO PERMIT ISSUANCE.
1(the designer in responsible charge, Architect or Engineer) hereby certify that I have read and examined the above
application and checklist, and that all of the information provided and items checked are included as part of the initial permit
application submittal and are true to the best of my knowledge.
7/31/2019
Signature Date
***EXAMPLE ONLY***
THIS INFO TO BE PROVIDED ON PLANS
(may not be all inclusive)
City of Twin Falls
Plan Analysis Based on Latest Edition of IBC & IFC
Architect or Engineer of Record:
Job Address: City: St: Zip:
Legal Description:
Occupancy Classification: Occupant Load Per Area: 1: 2:
3:
5: 6:
Number of Stories: Vestibule Req'd?: Yes: No: Total:
Floor Area: Basement: 1st: Exits Required: Basement:
2nd: 3rd: 4th: 2nd: 3rd: 4th: ries
Actually furthest travel distance to exit: (IBC Table 1016.1 &Table 1021.2
Type of Construction: Allowable Area Calcs:
Area Increase:
Sprinkler System: Yes: No: Exit jjgn es: No:
Maximum Floor Area Allowed: Emergency Lights: Yes: No:
i
Special Inspections Required? Yes: No: Lighting Layout&ComCheck: Yes: No:
v 0."
Firewalls Required?Yes: No: (If Yes, please provide cross section & UL Listing)
Occupancy Separation Required? Yes: 0 If Yes, please provide cross section & UL Listing)
Area Separation Required? Yes: No: (If Yes, please provide cross section & UL Listing)
Classified Areas? Yes: No: (If Yes, please show on plans and explain classification)
FIRE HYDRANTS WITRMF
I&�. � Comments:
1. ft
2. ft. low:
3. ft. GPM Flow:
Total:
Minimum Req'd Flow for Building:
Model Required?: Yes: No:
Date: Prepared By: ***Fee may be accessed for water model***
CH2MHILL
CH2M HILL
P.O.Box 5158
Twin Falls,ID 83303-5158
Tel 208.734.9933
Fax 208.734.9937
Dear Wastewater Customer:
The City of Twin Falls is required by the Environmental Protection Agency(EPA)to conduct a Wastewater Survey of the users
within our service area. The reason for this survey is to determine if any wastewater discharged would be detrimental to the
wastewater collection and treatment system or the treatment process.
For purposes of notification, all industrial users (i.e., non-domestic users) are required to notify the Wastewater Treatment
Facility of hazardous wastes in accordance with 40 CFR 403.12 (p). (See back of letter)
We are asking that you please fill out the attached questionnaire as accurately and thoroughly as possible, and return it to us
in the envelope provided within the month. Please make sure the name of the company, address and a contact person is
included on the form.
In the next few weeks after the survey has been submitted, you may be contacted by telephone or in person by a
representative from CH2M HILL to answer any questions you may have and to gather any additional information we may
need for this survey.
If you have any questions, please contact Rebekka Bicart at 734-9933, or email "rbicart@ch2m.com".
Thank you for your cooperation.
Sincerely,
Rebekka Bicart
Industrial Pretreatment Coordinator
CH2M HILL
40 CFR 403.12 p)(1)The Industrial User shall notify the POTW,the EPA Regional Waste Management Division
Director, and State hazardous waste authorities in writing of any discharge into the POTW of a substance,which,
if otherwise disposed of, would be a hazardous waste under 40 CFR part 261. Such notification must include the
name of the hazardous waste as set forth in 40 CFR part 261, the EPA hazardous waste number, and the type of
discharge (continuous, batch, or other). If the Industrial User discharges more than 100 kilograms of such waste
per calendar month to the POTW, the notification shall also contain the following information to the extent such
information is known and readily available to the Industrial User: An identification of the hazardous constituents
contained in the wastes, an estimation of the mass and concentration of such constituents in the wastestream
discharged during that calendar month, and an estimation of the mass of constituents in the wastestream expected
to be discharged during the following twelve months. All notifications must take place within 180 days of the
effective date of this rule. Industrial users who commence discharging after the effective date of this rule shall
provide the notification no later than 180 days after the discharge of the listed or characteristic hazardous waste.
Any notification under this paragraph need be submitted only once for each hazardous waste discharged.
However, notifications of changed discharges must be submitted under 40 CFR 403.12 0). The notification
requirement in this section does not apply to pollutants already reported under the self-monitoring requirements
of 40 CFR 403.12 (b), (d), and(e). (2) Dischargers are exempt from the requirements of paragraph (p)(1) of this
section during a calendar month in which they discharge no more than fifteen kilograms of hazardous wastes,
unless the wastes are acute hazardous wastes as specified in 40 CFR 261.30(d) and 261.33(e). Discharge of more
than fifteen kilograms of non-acute hazardous wastes in a calendar month, or of any quantity of acute hazardous
wastes as specified in 40 CFR 261.30(d) and 261.33(e), requires a one-time notification. Subsequent months
during which the Industrial User discharges more than such quantities of any hazardous waste do not require
additional notification. (3)In the case of any new regulations under section 3001 of RCRA identifying additional
characteristics of hazardous waste or listing any additional substance as a hazardous waste, the Industrial User
must notify the POTW, the EPA Regional Waste Management Waste Division Director, and State hazardous
waste authorities of the discharge of such substance within 90 days of the effective date of such regulations. (4)
In the case of any notification made under paragraph(p) of this section,the Industrial User shall certify that it has
a program in place to reduce the volume and toxicity of hazardous wastes generated to the degree it has determined
to be economically practical.
For links to 40 CFR regulations go to www.gpoaccess.gov and click on Code of Federal Regulations.
Wastewater Survey
City of Twin Falls
1. Company Name: Elizabeth Partners
Mailing Address 621 N. College Rd, Suite 100
Twin Falls ID 83301
Telephone: 208-734-4888 Fax: 208-734-6049
Email: gmartens@ehminc.com
2. Facility Address: 1854 Elizabeth Blvd
If same as above Check ❑
Telephone:
If same as above Check 0
3. Contact Person: Gerald Martens Title: Owner
Telephone: 208-734-4888 Fax:
Email: gmartens@ehminc.com
4. Type of Business Please Check all that apply to activities at your place of business.
Retail—describe type(to the right),
® Small Office—describe type(to the right)
If you Checked either Retail or Small Office for your business type and none of the descriptions below apply to your business,please
answer Questions 5&6,and skip all other questions. Please be sure to sign and date this form prior to returning
Motels/Hotels/Clubs [3 Schools/Colleges/Universities
Concern is efficiency of kitchen grease traps,frequency of clean out, Concern is efficiency of kitchen grease traps,frequency of clean out,
disposal of grease. disposal of grease.
❑ Laboratory— Pharmacies ® Laboratory—Commercial &
Concern is hazardous materials,disposal of chemicals,and potential Schools/Colleges/Universities
for spills. Concern is hazardous materials,disposal of chemicals,and potential
for spills.
® Hospitals ® Dental Clinics
Doctor's Clinics ® Photo Shops
Concern is with silver recovery.
Restaurants
Concern is efficiency of kitchen grease traps,frequency of clean out, 0 Barrel Reclaimers
disposal of grease
® Print& Photo Copy ® Arts &Crafts Shops
Concern is with paints&glazes(ceramic&other).
® Garages/Full Service Gas Stations ® Radiator Shops
Concern is flushing of antifreeze contaminated with metals.
C1 Paint& Body Shops ® Transportation Facilities
Concern is improper disposal of waste oils and inefficient grit traps.
® Industrial 1 Commercial Laundries ® Waste Haulers
EJ Other— Describe principal activities or the nature of processes at the facility, in the space
provided below.
Residential 4 plex units
5. Number of Employees:
6. Operating Schedule: hrslday days/week
7. Standard Industrial Classification Code Number(s)and Classification(s)(if known):
8. Average total monthly water usage in gallons(monthly water billings will usually snow this).
9. Is the building presently hooked to the sewer system? Y O N O
10. Are there floor drains present at your facility? Y O N O
11. Do you or will you use non-petroleum fats,oils or greases(cooking types of oil/grease)in your Y O N O
business?
12. Do you or will you use petroleum oils or greases in your business?
YO N �
13. Grease trap present? Y O N O
14. Describe any pretreatment facilities or practices used to remove pollutants or protect the sewer.
15. Do you or will you store or use chemicals on site in excess of household quantities? Y O N O
16. Do you or will you discharge wastewater(other than domestic wastes from toilets,showers,etc.)to the Y O N O
sewer system?
17. Do you or will you have an Accidental Spill Prevention Plan(ASPP)for your business? Y O N O
1 certify that the information in this questionnaire is to the best of my knowledge true and complete. [This statement
must be signed by an official authorized to sign for the company.]
Signature: Date: 7/31/2019
Print Name: Gerald Martens
OFFICE USE ONLY
Additional information required?
Need to schedule site visit or other follow-up? Y O N O
Need to send an Industrial User permit application? Y O N O
HAZARDOUS WASTE INFORMATION/NOTIFICATION(make copies&attach additional sheets if necessary)
Type of Discharge:
Name of Waste EPA Hazardous C—continuous Describe Other
# Waste Number B—Batch,0-Other
1
2
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3
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4
5
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6
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7
8
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9
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10
If more than 100 Kilograms (220 pounds) of any hazardous waste per calendar month is discharged to the sewer, please
include the following items of information for each hazardous waste, to the extent such information is known and readily
available.
HAZARDOUS CONSTITUENT INFORMATION:
Concentration in
Name of Constituent Mass in Wastestream Wastestream Mass in Wastestream
(this month) (this month) (next 12 months)
...............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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The US Environmental Protection Agency requires that
Renovation, repair and painting projects that disturb
lead-based paint in pre-1978 homes, childcare facilities and
schools must be performed by an EPA Certified Renovator
working for an EPA Certified Firm and specific work practices
must be implemented to prevent lead contamination . More
information is available at 1800-424- LEAD [ 5323 ] or
http : //www2 . epa . gov/lead
Laurie Fay
US Environmental Protection Agency Region 10
1200 Sixth Avenue
Suite 900, MS AWT-128
Seattle, WA 98101
Phone: 206-553-1541
Fax: 206-553-8509
Email: fay.laurie@epa.gov
You may also find information about Asbestos at
http : //www2 . epa . gov/asbestos or the State of Idaho has
information on their website at http : //deg . idaho . gov/air-
quality/air-pollutants/air-toxics/asbestos . aspx
Please note that EPA R10 in Seattle handles asbestos in
schools (AHERA regulation) . R10 Seattle no longer handles
asbestos NESHAP issues - these are referred to John Pavitt,
EPA R10 Anchorage, AK office - his contact information is
phone (907-271-3688) and/or email (pavitt . john _epa . gov) .
SEWER CAPACITY FEE WORKSHEET
Business Name: Elizabeth Apartments Address:
1. Please indicate the number of new and exisiting plumbing fixtures in the appropriate boxes below.
2. Also, the number of holidays being closed, the number of days the business is open in a week, and how many hours open
during the day.
3. If no plumbing fixtures are bing installed, signify at the bottom of the form and sign.
4. Sign and date.
VALUES Number VALUES Number
New DFU/Unit Existing DFU / Unit
Lavatories 8 Lavatories
Water Closets 8 Water Closets
Urinal Urinal
Water Softener Water Softener
Hand Sink Hand Sink
Dishwasher 4 Dishwasher
Bar Sink Bar Sink
Clothes Washer 4 Clothes Washer
Kitchen Sink 4 Kitchen Sink
Shower 8 Shower
Drinking Fountain Drinking Fountain
Mop/Svice-Sk/Tr Dr Mop/Svice Sk/Tr Dr
Hose Bibb Hose Bibb Holidays
Laundry Sink Laundry Sink Days/Wk
Floor Drain/Sinks Floor Drain/Sinks Hrs/ Da
Swimming pool Swimming pool
Hot tub/whirl pool Hot tub
Other Other
*No plumbing fixtures are being installed. Initial
Signature below indicates all information provided for on this form is accurate.
NameGerald Martens Date7/31/2019