1986, 10-03 Permit App: 00012082 Move Residence132 if
(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)
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Owner's Name MI
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Project Address (Street Name & Number) J Zip .
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Applicant
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Address '
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City
—CL 402 /-
State
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Zip
970 37
Phone _
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Business Phone
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Contr or/Agent �/ e . i
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States A
Zip S/'
Phone
Contact
License Number (Req Ired)
LOt°NZz3Q13
Business Phone
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Architect/Engineer
IIIL'8�
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Address
City
State .
Zip
Phone
( )
Contact
Business Phone
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Lender
Address -
City
State I
Zip
Phone
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Describe Work .. ,. _ - - r . ' :• - .. -
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Subdivision/ plat Name/Short b Plat Number,- - , s .} . • _ - -
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Assessor Parcel Number .. ..
447 7 ss'% — / 707.. ..
:Lot': ."",.�a:".
3' .
.Plat Number'
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—.Pertinent Fee Numbers • -' -
•Zone'
'Comp: Plan— "'- -^^'
Census Tact "�''^' ^ �' ' •`:"
• Number of Dwelling Units
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Number of_Buildiinngs '-
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.Lot Size (Sq. Ft./Acre)' .,s -
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Depth '.
Frontage..+.::. -:'•.'d: �y..
hent Setback
Left Setback :. ' -
Right Setback -
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Rear Setback ,' .. 1, -
R/ W Width'......--• -,-
Additional Information - 9(00 'A-' ,•
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INFORMATION '
Square Footage."m�',i --7 y:.1:
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Number of Bedrooms '
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Building Technician'- _ •
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• Date -
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Group....
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Environmental Health
W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Application #
4rii-d°/ L4
Approved
Cond.
Approval
Hold
Planning/Zoning
❑ N. 721 Jefferson
/ Engineers
I� N. 811 Jefferson
Ring.
4i?0r 383
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 to compile said application is true and correct' ;:>
Signature Date
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