1986, 06-12 Permit App: 00011551 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)
SHADED AREAS AR
- v V
I Project Number % /55/
+
Owner's N7� � � LAST FIRST
�F MI
1 I
Project Address (Street Name & Number)
Zip
('+'L2 Pie- k 4,...,e2 o -y► l2 • q GI "Z/ Z
Applicant
7—`j3 • DOOre_41 r
Address
/ 50 k) 6if-1`
City
V e
State ' - /
Wq
Zip
°f g2o
— --
Phone
(6b7) #35-5363
Business Phone
l 1......
Contractor/Agent
15 '
W c__
Address
2:2, c i s, ii/k, „' A
City
State
Zip i R2027
Phone
(&r-2T) q• ct 3
Contact
License Number (Required)
1F79-tA Cc,c c
i 8 2 J 7
Business Phone
( g
Architect/Engineer
lel /F
7
Address
City
State
Zip
Phone
( 1
Contact
Business Phone
( )
Lender
Add ess
City
State
Zip
Phone
(
Describe Work ,/
Vee-1,L`e'llC{
Res,
c/
Comm.
Subdivision/PI mel Short Plat Number
tiX1/1.p�kc
k -77 f5 1fq
Assessor Parcel Number
I p141' 2)._ ei / 2/1 ( �a Z
Lot
2 &
Block
L
Plat Number
664,57C/0Z-00
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling units
1
Number of Buildings
/
Lot Size (Sq. Ft./Acre)
Depth l t/bG 9
Frontage�
( V %
Front Setback
41.6-, I
Left Setback
Right Setback r
Rear Setback f
C—
R/W Width t
Additional Information
BUILDING INFORMATION 1
Square Footage
Number of Bedrooms
Building Technician
: .: )
Date
&,—/� Et,
Group
e-3
Type
vN
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
Approved
Cond.
Approval
Hold
/Environmental Health Application #
/.1/A
W. 1101 College
Room 200 I I2E,4T)-1 IJT PLAT
/ Planning/Zoning
N. 721 Jefferson
/ Engineers
N. 811 Jefferson EV f ST7 C1 a- .AFPIP-OACif
Utilities _
N. 811 Jefferson
/Plan Review/Fire Prevention p /f 3 4
N. 811 Jefferson
Other (SEPA/Critical Material/ate.)
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
-1 53
4)
1
LT!
t_ I
1 ii
ovTLfZpP •
'� -- �_ l r• ywp,T jam �v\ Q
cc -4-4 N ELT 1v
. E'(mNq-
. NI-
J
I
5. 177
r
!Gu _
`y.._ I ,I • LlJ
c t4 NeciT i (
i
it5c.1 Ha
Es-'
—4
1
t -Acv-+ rt0 -V i.
t
t�
t
fi