1986, 04-02 Permit App: 00010401 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)
b'MAUtU AMtAb AMC YUM Lit YAM I MtN I AL Ubt
Protect Number
Owner's Name LAST FIRST MI
bG/. /C _ S' R /17oc . /4/ C
Project Address (Street Na e & Number) �+ Zip
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Applicant
Address
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City
State
Zip
Phone
( )
Business Phone
( )
Contractor/Agent
W, 2 . C /S
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Add
ess
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City
Cl/Y"‘'-
State
G%/t-/
Zip
.7-2/V
Phone
( ) fid —on -a -
Contact
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License Number (Required)
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ecrrid76
Business Phone
( 1
Architec lEngineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone .
Describe Work�f
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Res.
Comm.
Subdivision/ Plat Name/Short Plat Numb9/
Assessor PCC
al
mbar ��
Ni
Lot
Block
/
Plat N 5�
_
Pertinent File Numbers
Zone ;fa-,
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Front Setback ,.„,-.-
S
Left Setback �
/1
Right Setback
/7
Rear Setbac /
6.1
R/W Width
Additional Information
I BUILDING INFORMATION
Square Footage
/09 /--��
50t/ tie
Number of Bedrooms
Building Technician -
Jut m •
Date
4-7436
Group
k --3
Type
�Nl •
DEPARTMENTAL REVIEW
I certify that 1 have examined this application and state that the information contained in It and submitted
by me ormy agent to compile said application Is true and correct.
Signature Date
gP;LAPProvaI
Cond.
Hold
Environmental HealthApplication #
W. 1101 College
200
GGl61y5
Room
Planning/Zoning
N. 721 Jefferson
Engineers I
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N.811 Jefferson .L�i
C-4-1--0-1 sae-
(7044/
Utilities
] N. 811 Jefferson
Plan Review/Fire Prevention
//-ts-8c,
] N. 811 Jefferson
_
Other (SEPA/Critical Material/etc.)
7
Fast Track/Special Inspection Information
]
Project Representative
Phone
Address
I certify that 1 have examined this application and state that the information contained in It and submitted
by me ormy agent to compile said application Is true and correct.
Signature Date
I z -2.0�
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