1984, 06-19 Permit App: 00000741 Remodel•
•
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your bullding plans to the Department of Building and Safety)
1 Owner's Name (last) (first) (m) Department the Only
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Liss-E/l/�/
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2 Proles S (not Mailing or Road eQ- & Space c7Zp
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3 City/Community /1
D �E
State
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Subdivision/Plat Name
t J,O(j,A ' I. oF S ZIS oF
4 Assessor Parcel No
275 1 - 1U-1✓
i
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zoite Act.. #
Zone ,�/���%+�� i{�( Project No. �7 c4 I
6 Dwell N
No. of Buildings
8
Sq. Ft. Acre
Deptthh
Frontage
7 SetBack-Front i_
(L 5-1
(R)S-2
Rear
census Tract
Module No.
Initials
NJ /y�
16 Architect Ftrm Name I Street Address
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Zip
CI"
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name/G /
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Street Address -e
E., /79/3 0-/
Zip9 �-v G
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State �/
Phon(co 7) q; V- s° 7
/
License
No. .4 (I (� 1
Phone if different than above
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Owner/Agent (if different than /11 above)
Busl ass Address
9 Zip
City
State
Phone
1 )
12 Review Required
Plan Check (V/N)
Other (Y/N)
SEPA Exempt (V/N)
Date
15 Type Work Bldg
0 Fire
0 MH
0 Demo
0 New
' .Add)Alter
0 Replace
0 Move
0 Other
14 Describe Work
It
_ OSS 0E -A•4/ I N V
10 Applicant Name ������yy"�F
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-- �" f r. ' ' v .
Street Address
11 Zip
City
State
Phone
( 1
Lender
Street Address
Zip
City
State
Phone
( 1
Contact Person
Phone If different than above
( )
Additional Information
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