1986, 04-17 Permit App: 00010519 SidingU..4(_*,
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department .o/ff Building and Safety)
QtAY
1 II ) (first) (m) UaeAnly
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2 Project Address (not Malting Addrs) NemE Space Zip
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3 City/Commynity
State
1.6)/pc•
Subdivlsion/Plat
U
Name
3 _
4�i��u
Parcel No.
� 2-16 6
Lot
I
Block
3
+ + + DEPARTMENT USE ONLY * * *
5 Sic Cade
Zone Act. a
ZoneProject
[2-0—
No.
/e5Q
6 Dwell#
No. of Buildings
Sq. Ft./Acre y
f ��
Depth
Frontage
7 Set BSc -Front
(L S-1
(R)S-2
Rear
Census Tract
Module No.
Initials
16 Architect Firm Name ( Street Address
Zip
Qty
State
Phone
1 )
Contact Person
Phone If different than above
1 )
Contractor Firm Name
1—file-1/
Street Address
7l. 3` /c(otiel../
Zip
g,-/ a
Qty
/ )
State
_ (J) .
Phone9
(9a)
Cant Person
MeO
License No.
»" ge3y6�E
Phone If different than above
1
S Owner/Agent' different than #1 abov
Business Address '
9 Zip
City
State
Phone
1 )
12 Review Required
Plan Check (Y/N)
Other (YIN) J SEPA Exempt (YIN)
Gate
15 Type Work 0 Bldg
0 Fire
0 MH
0 Demo
0 New
X Add/Alter
0 Replace
0 Move
0 Other
14 Describe rk q /y
ete
10 Applicant Na a
Street Address
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone II different than above
Additional Information •i O✓
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