1986, 08-08 Permit App: 00012534 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)
Project Number
Owner's Name LAST k FIRST MI
3R /�v/A/6 !/ 4n/
Project Address treet Name & Number) / , Zip
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/To 7 t' E (7-5 5f),KAIr.) L/iQ• T 1,
Applicant
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Address n�
S, 3004 %�(c o v, S
City n
S f e9kWitJE
State
4)1A
Zip
Tit? -,14
Phone
1 ) to2 F-4.,? P F
Business Phone f )
( )
Contractor/ tient
vl two C % Y LE/AA)
Address /�
S ' 3 064 /il cQ,'U/aLb
City
5 pO!(1vvE
State
Ar
Zip
,rfob►i�i
Phone
1 I k.�'6, 7-
Contac License Number (Required)
L.EiiVu TA y OA
Business Phone
( 1 f
Architect/ Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
1 I
Lender rdd ess
City
State 1 Zip
Phone
( I _
Describe Work
Res. Comm.
Subdivision/PIat.Name/Short Plat Number
Assessor Parcel Number
Lot
Block
Plat Number
Pertinent Fife 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
Roar Setback
Additional Information
DEPARTMENT USE
Square Footage
•/-
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Building Technician Bite '
Group •
DEPARTMENTAL REVIEW
_
Approved
Cond.
Approval
Hold
Environmental Health Permit Number 4 2
11
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P to
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W. 1101 College
Room 200
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r ,.Firer
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A JrI4 'rFTSar MilMillM
Planning/Zoning-
N. 721 Jefferson- 1
Permit Number
Engineers -
N. 811 Jefferson - --1
r
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
4-,
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