1986, 10-28 Permit App: 00013981 Duplex(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 I
Project Number /�/ye�/
✓✓ �� vv
Owner's Name LAST FIRST MI
•
Project Address (S ket Name & Number) "' Zip
Applicant 6/:2-7-
/(_/'4 ^ 'C n 7" t'L t�0
Address
Jv' ` �/ -;,, % %/„ /tet
-) ., .
City /.
) -4/1--,a,..-)/1-141
State
.
Zip „„)
t-3(= 4
Phone
( ) .,F -,-`� ,9
Business Phone
Contractor/Agent
i
Address
City
State
Zip
Phone
( )
Cont ct,
c, -G> 2e e-' ,' 7
License Number (Required)
zooi_, F L 2, 4 /--/-%,(41 .
Business Phone
( )
_
Architect/ Engineer
Address
City
State
Zip
Phone
( )
Contact°
Business Phone
( )
Lender
Address
City
State
I Zip
Phone
•
�"�JM
F1�It.
Gomm.
.4iRI`VSIY„t'7#}��w[-Rfkd'j/.,y�vSllyYme1$1,#V#t Piat ji#=i
FFWM
/
f�.fM
s Ptt ..
Tract
($q. t .IAc e)
i.
gMVW V PWa�w ...
L
r
0
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 true, correct, legal, and binding.
Owner's Signature —
1v�
Date
Approved
CpApproval
Hold
Environmental Health Permit Number
g
—/-VV O
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
(1)
i(Nolumber
2)_)_5
/9
Engineers E A j'
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
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 Signature —
1v�
Date
w
•
4.95/C /4/5 Dc.) P1. c 7<
,q4. 770.12 NA r4- ''B
S'
,5'
3
It
/Od0 SA •
Duras
CLrnp7 sur
f in'�SN rL. a
n
15
.rs
a- 8
3 S'
3/41 1.3t17r'.
Do, Bc.e PC M 3 E1.)
-X-11"P.✓.c. Ar ? X. Sw
AsTrn D -30341-SD-35
- CA PPE D c.dDS.
et
Lori , &g. TowNEIZS Apt) Gor/L/3[g. rac.JNE2S /DO-
S Ailki 967 C41-0/14 sr. IApp CAl.via .5r.
go La r rfr/sie
9�r