1986, 09-05 Permit App: 00012982 ResidenceTHIS lQ1 NOT A PERMIT)
BUILDING PER"Affl-
E 4- PtACATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY TH'OSE PARTS OF -f-HE FORM YOU UNDERSTAND
COMPLETE IN lNK
(Please return this original and your t)uilcfing plans 'toJhe . Do.Dartment of Building and Safety)
SHADED AREAS ARE FOR DEPART 1,21 ENTAL USE
Project t Num,
Owner's Name I A' ST Ml
Project Address (Street Na & Number)
Z;p
/V
Applicant
1'5 -7 t17
Andre s
-71,?
City State
Zip Phone
Business Phone
Contractor/ Agent
City State k
71p� JJ Phone
7
Contact
1i
-9
Business Phone
All
Kn� � / +0 AA 7- C_
—I &_)1,t
Architect/ Engineer
— —
Address -
City State
1 zip Phone
Contact
Business Phone
Lender
Address'
City State
I ZIP Phone
Describe Work
,ZK NK
".4 47 Al
2-36
R
0;" Res,
Assessor Parcel Number
Lott k"`2�
tocPlat N mber
"
Portloent File Numbers s
Zone Plan
Comp an -ii
umbiirblf cUBUildings�.,','-:
Lot Si7e (Sq� Ft./ ArreY..'- mpth 7' _-Frontage
S,
o
N, .7
Right Setback
'Aa Rear Setback R
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DEPARTMENTAL REVIEW
1 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
Date
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200 /e
D`
Planning/Zoning_ =
N. 721 Jefferson
Af
�
Engineers 7,V D
N. 811 Jefferson:�i�
ell dv
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
1 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
Date
.
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