1986, 01-28 Permit App: 00009512 Addition, Plumbing Fixtures(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)
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Project Number 'o'.
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Owner's N An a LAST FIRST MI
Project Address (Street Name 81 Number) Zip
S ,� z i g A iv v R D Y&yeADAL-- u.ii4 . 99a 37
Applicant
,.7-6/ 0 y Row LAMJ
Address
s 14 m
City
State
Zip
Phone
(5b) 902 — 9 9/
Business Phone
( )
Contractor /Agent
,Sar )
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect /Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
Describe Work
ADD , t at,-; c, --- ; D (-- -L.
FA 01 ; ! P [ NI i f\1 r
_ BN't}i
Res. i
Comm.
Subdivision /Plat Name /Short Plat Number
." (✓I lit O t5(Ury
Assessor Parcel Number (r,
Lot 61
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft. /Acre)
Depth
11
Frontage
76 .9
Front
Setback'
( (7 S1
Left Setback
IAA,
Right Setback
J
Rear Setback
— —
R/W Width
Addilonallnformation
1 BUILDING INFORMATION
Square Footage
-- 1, f f ) .rn 61 N u
— C{"iD .J
Number of Bedrooms
Building Technician
Date
Group
Type
DEPARTMENTAL REVIEW
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.
Date /— Q7- O
Approv d
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
.B-IC
Planning /Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
1
Plan Review/ Fire Prevention
N.811 Jefferson
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1--2'6.-F:•(.-
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Other (SEPA /Critical Material /etc.)
Fast Track /Special 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 compile said application is true and correct.
Date /— Q7- O
N