1986, 04-21 Permit App: 00010616 Garage(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 & Number) Zip
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Applicant / /
Address
City
.57,ek i4 /t1
tater
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Zip
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Phone
(-re"e7) Q'. i -- CY (s - 7
Business Phone
( )
Contractor/Agent
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect/Engineer
Address
City
State I Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State I Zip
I
Phone
l
DescribnbeVllork' T' I I F'T`C
Res.
Comm.
Subdiyision(Piat NamelShort Piet Npmber
Assessor Parcel Number /
t..Vell
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Lot
Block
Plat Number
Pertinent File Numbers Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Front Setback
Left Setbackt
Right 1 Setback
Rear Setback
R/ W Width
Additional Information
BUILDING INFORMATION 1
Square Footage
Number of Bedrooms
ng Technician
Date
Group
Type
DEPARTMENTAL REVIEW
-af
Approved
Appovprov al
Hold
d
Environmental Health Application #
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'
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
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
r GILA; e„,
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