1985, 07-31 Permit App: 00006654 Residence(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)
OM/AL/CU mn CMJ rr1C rVr1 UCr'Hr1 1 IVICIV 1 HL L./0C
Project Number i_
�L/
Owner's Name LAST FIRST MI
51 A/'' r7Y�'�bJ" O 7 a i1/7/F?
Project Addressdrreet Name & Nu ber) Zip
(2 7 v2, QQ .e' `--
/-/
Appl icant
Address
City
State
Zip
Phone
( )
Business Phone
( )
Contractor /Agent
__,..f .4./es? ,d.vai 67/- J /i5,7;c7.4,,e
Address
42 -6,2 ,,'''f-'7-,", „-
City
W:04/6"
State
1 ,./ '
Zip
��a/l
•
Phone
( ) 2/c —.27/
.
Co act
� c� License Number (Required)
/,i�it/ �iq .J � J/%N S /5.7
�y �
�_7—
Business Phone Z--
7
( ) %P. �c,77/L�
Architect /Engineer /
Architect
e_f>,..„../ /J%�,o y lc.
Address
City State
I Zip
I(
Phone
)
Contact -,
Business Phone
Lender
/� �7
Address
Cit
/lug'
State �
---../.--7.-"q/.., 2�
v-•
ZipPhone
ibe ork
/ ,r
Res.
Comm.
. Subdivision/Plat Name/Short Plat Number
r ak.(2,40;Cr... 1J(e L.3 t TA-TE1 1100 k—n(0. j
Assessor Parcel Number
`%S41 -- OoC441 6:'N
Lot
t
Block
1
Plat Number
Pertinent File Numbers
Zone
Comp. Pian
Census Tract
Number of ()wailing Units
Number of Buildings
Lot Size (Sq. Ft./Acre]
Depth
Frontage
Front Setback t
Left Setback
.0`
Right Setbacig
t4
Rear Setback
Additional information -
I DEPARTMENT USE
Square Footage
r•"" 1556'
Ur, 1b 115A0
2_..
iding Tech an' . [
4:4•^-,
a /
Group
Jt
T
3 +
DEPARTMENTAL REVIEW
Approved
pp
Apprrovov al
Hold
Environmental Health Permit Number er7r - o?o�
W. 1101 College
Room 2,0,�0/
3/
4 46.-77
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Planning/Zoning
N. 721 Jefferson
Permit Number_
'7 1 -,-4
Engineers
N. 811 Jefferson
/1
❑
Utilities
N. 811 Jefferson
i rd(
Plan Review/ Fire Prevention
N. 811 Jefferson
at
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 is true, correct, legal, and binding.
Owner's Signatur
Date
4.0
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