1986, 07-31 Permit App: 00012402 Addition(THIS IS NOT A 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 It
/z V
Owner's Name LAST FIRST MI f-
E I Nay V
Project Address (Street ame & Number) Zip •
E llc(04/ F g fLIE 21c /< 992x
Applicant
D6we: y w. /
Address
City
s41e/SoAt
Zip
I
Phone
I )
Business Phone
1
Contractor/Agent
H 4 A(33A1-CA42.1-6
g C.AtSi-
Address
A • • Sr./4k/e/ N let
City
5t9dlillA/h
State
U//}
Zip
91421(
Phone
I 1 92E3 -7v.
Contact
flE_VIF_ y WAA/sox/
License Number (Required)
/iAA/So cc. /'i -
_
Business Phone
l I z8 - 7v sz
Architect / Engir/eer
Address
City
State
Zip
Phone
()
"
Contact
Business Phone
(
Lender
Address
City
State I Zip
Phone
I 1
pe8�ribe Work '•
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DEPARTMENTAL REVIEW
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agac�t to compile said application is true and correct.
Signature
Date 7/3/he
e
Approved
Cond.
Approval
Hold
Environmental Health Application R
O J O
r/Ai Ori
W. 1101 College
Room 200
41'
1
, ,l
/ i{��"• Ln,L n o b ( WiAim"
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
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 agac�t to compile said application is true and correct.
Signature
Date 7/3/he
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FIPOR
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