1986, 04-28 Permit App: 00010745 Remodel Basement(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)
Project Number 1 0 ---74_
Owner' Name_
i. LAST FIRST MI
e) z_ n, /1/ , ticl 4
jest Address (Street Name & Number) Zip
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Applicant
Address
City
State
Zip
Phone
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Business Phone
( 1
Contractor/Agent
C
Address
City'hei�/()
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State
0/4- .
Zip
9922__
Phone
(s01 )//A"/sT
Contact
License Number (Required)
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4YC59
Business Phone ` J
( ) I
Architect/Engineer
Address
City
State
Zip
Phone
( I
Contact
Business Phone
( 1
Lender
Address
City
State I Zip
Phone
(
Describe Work •-
e,
Res.
Comm.
Subdivision/Plat Name/Short Plat Number
C,L..`i )F(-%) fv ZN
Assessor Parcel Number
2-6, 54E _ " .2-1 t ci
Lot
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units :.
Number of Buildings
Lot Size (Sq. Ft. /Acre)
Depth
Frontage
Front Setback
Left Setback
Right Setback
Rear Setback.
R/W Width
Additional Information 4
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BUILDING INFORMATION
Square Footage
Number of Bedrooms
... w .q
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 agent to compile said application is true and correct.
Signature Date
Approved
Cond.
Approval
Hold
Environmental Health Application #
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
2 ,f
Cl
Other (SEPA/Critical Material/etc.)
Fest 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