1985, 08-20 Permit App: 00007012 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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
IProject Number
Owner's Name
LAST FIRST MI
Project Addres��� Name & Number)
/yu��ir
Applicant
Zip
Address
City
State
Zip
Phone 5 C'f r
( C,_4/057
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
( 1
Lender
City State
Address
Zip Phone
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 is frde, correct, legal, and binds9g..
Owner's Signature
Date
(7 ,gg: 5
Approved
CpApproval
Hold
Environmental Health Permit Number
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Plan Review/ Fire Prevention
N. 811 Jefferson
Other (SEPA/ Critical Material/etc.)
Fast Track/Special Inspection Information
Protect 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 is frde, correct, legal, and binds9g..
Owner's Signature
Date
(7 ,gg: 5