1985, 09-24 Permit App: 00007660 Garage(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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number
Owngr's Name '" LAST FIRST MI
14), / An—
Project
n_Project Address (Street Name & Number) Zip
Applicant
Address
City
State
Zip
Phone
Business Phone
( )
Con tract or / Agen
Add ess
CityOfejl p
State
/4)A
Zip
Phone
) ga.ze--5S?
Contact
License Number (Required)
Business Phone
Architect /Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
( )
Lender
Add ess
City
State
Zip
Phone
(
Describe Work - -
&Ac 2- Z., > Z /
Comm.
Subdivision/Pia Name/ShortPlat Number
Pertinent File Numbers
Comp ;Plan
Plat Number
Census Tract
Number of. Buildings
Right Setback
Rear Setback .`
•
r,*
Building Techn ian
Date
DEPARTMENT USE
Frontage -
.1a
Group
N/1 -
Type
IJ
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 is true, correct, legal, and binding.
Owner's Signature,
Date
Approved
Cond.
Approval
Hold
Environmental Health Permit Number
NQ -'23-05W.
4N/0Ef
1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Permit umber
/n
9:13— :1j
/fit
Engineers
9 /
N. 811 efferson . //...../_ ii,i _
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,
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 agent is true, correct, legal, and binding.
Owner's Signature,
Date