1986, 04-02 Permit App: 00010399 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)
1 Project Number
Owner's Name LAST FIRST MI
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iProject
ProjectAddress (Street Name & Number) Zip
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Applicant
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iCity
Address
City
State
Zip
Phone
( )
Business Phone
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Contractor/Agent
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Add ess
DG? .._-e .C. /9CFV
City
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State
L2/11
Zip
y92 /V
Phone
( ) 72.07 -07,2_ -
Contact
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License Number (Required)
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Business Phone
( )
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
( )
Describe Work /J
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Comm.
Subdivision /Plat Name/Short Plat Num r
./L1l1MtL 11/S S snn' 30
Assessor Parcel Number
22759
Lot
Block -
/
Plat Number/
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Pertinent Fite Numbers
Zones FR---
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth 7
Frontage
Front Setbacks
g'' Left Setback
Right Setback
Rear Setbac
R1 W Width
Additional Information
BUILDING INFORMATION I
Square Footage`
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Number of Bedrooms
Building Technician
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Date
4-7-86
Gro
2u-3
Typep
V NJ
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DEPARTMENTAL REVIEW
3 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
Ap oved
Cond.
Approval
Hold
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Environmental Health Application # .f -e vS �
W. 1101 College
W�
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
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N. 811 Jefferson -/ ,0 - — <_. �. ; ._
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Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
N' 5-%
acr
Other (SEPA/Crltleal Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
3 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
0-
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