1986, 03-11 Permit App: 00010474 ResidenceS Si.
(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)
bHAUEU AMtAS AMt hUM UttAM I MLN 1 AL USC
I Protect Number
Owner's Name• LAST FIRST MI'
C --ft 11a 'D 'fir t,Nk6tZ a 7c eh
y
Project Address (Street Name & Numb r) Zip
E I 1 oat?, P000 ,E... A-oe •
Applicant �^
. 07ME 'VoN &2tGS8y
Address
/V/7.%2 LoeosT *V
City -State
& 00/114 YE
11/A -s4.
Zip
99 Lo 6
Phone
(• ) 949-.4 o6 0
Business Phone
1 1
Contractor/Agent
r
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
Architect/Engineer
Address
City
State
Zip
Phone
1 1
Contact
Business Phone
( )
Lender
Address
City
State
I Zip
Phone
( )
Describe Work -
Res. ye
. Comm.
Subdivision/Plat Na a/Short P1st Number
oppoa.to-wrf e
Assessor Parcel Number
1CRS1l' —• °CIBS
Lot
Block
Plat Number
Pertinent File Numbers
Zone
V-
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
LotSi' ze (Sq. Ft./ Acre)
Depth
14c '
Frontage
8'
s
Front Set ack
Left Setback T t
Right Setback
Rear Setback
R/W Width
Additional
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BUILDING INFORMATION
Square Footage
imF = 9n;
US..1V
cAit 14c
Number of Bedrooms
Building Technician
.coil m •
Date
3-H-8
Group
g - 3
Type
UN
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.
Signature Date
Approved
Cond.
Approval
Hold
Environmental Health Application#
W. 1101 College/f�/�
Room 200
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Planning/Zoning
N. 721 Jefferson
L_
Engineers � 7p
N. 811 Jefferson `�� ��
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/1
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention.
N. 811 Jefferson
3-(3-*
&d
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.
Signature Date
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Wi31, FTc
' L53(1 far GR y1e7
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