1986, 11-12 Permit App: 00014085 Remodel ��Z° ,Y
(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
• Project Number ` •
Owner's Name LAST FIRST ( S
N rA,STe-n-s e./(J Aa.l K
Project Address(Street Name&Number) Zip*
• N 1/S C.i/AI*fo4.) e4 e_ ivv, .. 99'.2.1 ,
Applicant i Address
e e A.,,sir LI I/P Ai
City l State Zip Phone
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Business Phone
(yg'3 ) .s—,s—‘
Contractor/Agent •
>> /) Address
T
et
City / State Zip Phone
k ,0e�a- _ 1.0" . 99zD7. ( '3) s'/s k
Contact f License Numger(Required) Business Phone
s7`cca.- J Q`A,e eE-s7`- /VC--n2.o O 8 3- (VO ) S-7 ,S k
Architect/Engineer Address
City State Zip Phone
I ( )
Contact Business Phone
( )
Lender Address
City 1 State Zip Phone
Describe Work Res. Comm.
Subdivision/Plat Name/Short Plat Number
•
Assessor Parcel Number • 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 Setback Right Setback Rear Setback R/W Width
Additional Information - - I Square Footage
•
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(ding TeehniciartDate —._.__... Group Type
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DEPARTMENTAL REVIEW
'
Approved
Cond.
Approval
Hold
Environmental Health Application #
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•
1 certify that 1 have examined this application and state that the information contained in It and submitted
by me or my agent to compile said application istrue and correct.
Signature •
Date