1986, 02-27 Permti App: 00009810 Addition(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
Owner's Name LAST FIRST
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Project Address (Street Name & Number)
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Applicant
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City.
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State
l%.rp
Zip
MI
Zip
Address
CL 7
Phone
),922y -ss- 74,
Business Phone
Contractor/Agente'elf1114,--) 0111 j
Address
i' ('s,= J (J
City
Contac
State
Architect /Engineer
Zip
License Number (Required)
0fei(- E' /7 3i - O td
Phone
Business Phone
( )
Address
City
Contact
Lender
City
State
Zip
Phone
Business Phone
Address
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 # J- C� G
e2��C�7
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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
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Protect 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
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