1986, 10-27 Permit App: 00013982 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)
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I Project Number Igo Z
Owner's Name LAST FIRST MI
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Project Address (Street Name & Number) Zip
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Applicant
DL. g4 lA N 2) co.
Address
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City
40 k4,fe.
State
Lai .
Zip
..10,,
Phone
`.Co2) 9a8 s'9 i
Business Phone
( ) S6 -r+18 J
Contractor/Agent
S
Address
City
State
Zip
Phone
( )
Contact
UI/11Ce Se,'/Yo
License Number (Required)
Lve9.-GL0__ Yli /4 2Vii
Business Phone
(...-----9 ) gad ---c2 -59.-2>
Architect /Engineer
Address
City
State
Zip
Phone
( )
Contact •
Business Phone
( )
Lender
g?/9-Nes,�i4-key/ L'/z4
Address
City State
I Zip
Phone
Describe Work
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Comm.
ivisionlPlat Name/Short Plat Number
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Assessor Parcel Number
.35 3- 3,3//�.3 — 3 4.1
Lot .5
it 14 1 4
Block
t
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Melling Units
Number of Buildings
1
Lot Size (Sq. Ft. /Acre)
/1J' x 9d'
Depth,I
.
ii -
Frontage
i6'
Fttmt Seti
0,
Left Setback ,
Right Setback to Q ,
Rear Setback
R/W Width
Additional Information
1 BUILDING INFORMATION
Square Footage
Number of Bedrooms
Building Technician
N
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Date
['0-7-8G
Group
Q -3
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y
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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 to compile said application is true and correct.
Signature
Date
/047/g
Approved
CpApproval
Hold
Environmental Health Application # ,..../.___---3
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers / i
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Utilities
N. 811 Jefferson
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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
/047/g
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