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1985, 10-30 Permit App: 00008523 Residence
(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 DEPARTMFNTAI HRF Project Number Owner's Name LAST FIRST M Project Address (Street Name & Number) Zip Applicant Address City State Zip Phone ^� Business Phone a Contractor/ Agent OXY) �► Address City State Zip Phone Contact License Number (Required) Business Phone Architect/ Engineer Address City State Zip Phone Contact Business Phone Lender Address n w+ _ 0 - 3 ©co City �y State Zip � r S ' Phone �' ✓ (.,G ) �� _ C Describe Work �.-�. Res.` Comm. Subdivision/ Plat Name/Short Plat Number Assessor Parcel Nu�m^b�eer� Lot Block Plat Number r 4✓ �' � � ��V� � t�y tt, Pertinent File Numbers Zone Comp. Plan Census Tract Number of DwellingUnits Number Lot Size (Sq. Ft./ Acre) Depth Frontage Front SetbackLeft Setback Right Setback Rear Setback Additional information Square Footage lv, f V is D ' H Z W E - Cr CL-.._- _----- - W p Group BuildingTecttnroian Date m `-- , 0 EE /J— �p, s P' loop _ An Cc CcArZAce_ .o! 1 I'a: v So a 3 ra - D �v� S CouRT s IN I oT /J— 9.40c< / IST k? v o v o DEPARTMENTAL REVIEW Approved gpproval Cond. Hold ❑ •�— . Environmental Health Permit Number W. 1101 College Room 200 ❑ Planning/Zoning N. 721 Jefferson _ Engineers Permit Number %_ D N. 811 Jefferson 6 ❑ Utilities N. 811 Jefferson i 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'sSignatur „„ i, �>^++_ Date /,gArd j