1986, 11-06 Permit App: 00014034 Addition(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)
Project Number
Owner's Name LAST FIRST MI _
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Project Address (Street Name & ) Zip
E.1 4 'FatC
Applicant,
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Address/
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State
Zip
95'4'(4'
Phone
( ) y4'—a 6
Business Phone
( )
Contractor/Agent
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 s 4 --'au ` 4 i
F, C, c I tc' To IN10125
I L E i51C
!
Res.
Comm. ,
..Subdivision/PIat Name /Short Plat Number
q •Is k) i "u1 ADO I TC%
essor Parcel Number
Lot
Block
Plat Number
Inent File Numbers
ZoneComp
�/n�
1` �
. Pian
Census Tract
umbar of Dwelling Untts
Number of Buildings
Lot Size (Sq. Ft./Acre)
Y.7-,
Depth /
Frontage
r
:Front Setback = , -.,' Lett5tback
Right Setback .
.Rear Setback_,
R/WWidth -
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Squre,Footage-. , x.
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BUILDING INI
- •
Number of Bedrooms
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Date //yA�
Group
Ty
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 ff 13 2=d r
\1
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W. 1101 College
Room 200
NECK e--6f'L( df s t i E PL f-)
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Pian Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
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
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