1986, 05-09 Permit App: 00010937 MH(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 Namet LAST FIRST MI
ic1e C, Piet a v.
Project Address (Street Name & Number) Zip
A' 4/606 ,ur'inS Rd '3kiaile Wi 4-.2./6
Applicant,� Address
Rbk Sr Cif I Al 116'067 6,ar43
City ^ //�� /
=.1 �o �'l a ✓i e
State
1 �� it 1 L. z. t
v rj
_Rd
Phone
(505') 92.F -6175
Business Phone
( )
Contractor/Agent
Address
City
State ''p
Phone
( 1
Contact
License Number (Required)
Business Phone
1 )
Architect /Engineer
Address
City
State j ZIP
Phone
)
Contact
•
Business Phone
( )
Lender
Address
City
State
Zip
Phone
( )
Wofk,, /
c=2;3?
Res.
Comm.
r tAVatii#4
/Piat, /Short Plat Number
ILO AV a IV %.mss
A, so.Parcel Number •
44 k t.1 ola
Lot
Block
Plat Number
Perttnertt f to Numbers ,
: L
Zone
A61it%
Comp. Plan
Census Tract
UWeltingUnits; ;
Vis* ..x .=,,-:.; .
Number of Buildings
,
Lot Size (Sq. Ft./Acre)
Depth
,
Ict5
Frontage
s t
Left Setback,
Right Setback
Rear Setback
R/WWidth
• Ytt Infamatign
u ...
Square Footage
Z
tom.
�... ..
2
O
u.
5
, ..
co
Number of Bedrooms
�� a
tate
_
Group
Type
DEPARTMENTAL REVIEW
I 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 is true and correct.
Signature
Approved p al
Appprrovov
Hold
Environmental Health Application #ji0#4471)1
f
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
I 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 is true and correct.
Signature
Jrns 'Rd.
WA 99211
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