1985, 09-25 Permit App: 00007693 MH(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)
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Owner's Name LAST (....FIRST mi
Project Address (Street Name & Number) Zip
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Applicant
Address
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City
State
Zip
Phone
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Business Phone
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Contractor/Agent
Address
City
State
Zip
Phone
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Contact
License Number (Rep
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Business Phone
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Architect/Engineer
Address
City
State
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Phone
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Contact
Business Phone
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Lender
Address
City
State
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Phone
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DEPARTMENTAL REVIEW
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proves
Cond
Approval
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Environmental Health Permit Number �/
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W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
Permit N.ber
Engineers - ,
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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
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