1986, 06-03 Permit App: 00011422 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)
..t 1r.1..1_v r.. 11-r..l r+nfl.. 1 vn 1JL fr fl 1 IVICIN 1 HL VJt
r e L
Protect Number / / 2.
Owner's Name AST t _ RST MI?
1 ' .- /lJ?
er)
Protect Address (StreetNam@ 8 3 25 C) y " n wc �T Zip /j\/f 3 �vW9.0/7,
Applicant
0"111/11E
Add ,,np
' A1C //32/
City
f 0/1(747tiF
State
ta
ZI
Phone
Business Phone
( 1
Contractor/Agent
Address
City
State
Zip
Phone
( 1
Contact
License Number (Required)
Business Phone
1 )
Architect/ Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( 1
Lender
Add ess
City
State
I Zip
Phone
1 1
Descrlbe Work
•: )//J –LE 0) ( DE 406 r! (.4%%)
Res.
Comm.
Subdivision /Pla�lame/Short Plat Number (! z–'`t« MEt_JT)
1j5A-JWCOD EAST
Assessor Parcel Number
(k5511 — 6103
Lot
3
Block
c
Plat Number
Pertinent Ffle NumbersZone
Comp. Plan
Census Tract
Number of Dwelling Units
/
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
11
Frontage
85
Front Setback
Left Setback
Right Setback
Rear Setback
R/W Width
Additional Information
BUILDING INFORMATION I
Square Footage
Number of Bedrooms
Building Techn Ian
Date
Group
Type
DEPARTMENTAL REVIEW
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agecompile said app on is tryet d correct.
Signature
""
Date `�' V
Approved
Cond.
Approval
Hold
t�
Environmental Health Application # 10 K. J g
3 --�o
+'
_" 44 i
. /
•-
W. 1101 College �/
w.
Room 200 -�
a/,, �/ /�, ,/
I0 exIl Ski u,-, ��-. 4 M- ..(r, . ,Cn- 4., aVF
��
444/4,#)
_ 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 I have examined this application and state that the information contained in it and submitted
by me or my agecompile said app on is tryet d correct.
Signature
""
Date `�' V
1
4
111
UM
MEM, , 1III
11
11111111■, I 1
)� d
-1
_.i
■
11E1,1111
=MU
BIEN=IL--I�
!!-_!...1U''__Il_1�
�_iLI
mid
ariMME
�al_ar75.,_ !is
1;