1986, 04-21 Permit App: 00010603 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 DEPARTMENTAL USE 11
Owner's Name/
LAST FIRST
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Project Address (StreerName & Number)
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Applicant
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State Zip
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Contractor/ Agent
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Contact License Number (Required)
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Business Phone
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Architect/ Engineer
Address
City
State Zip
Phone
Contact
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Business Phone
Lender
Address
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City —
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Phone
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Describe Work
Subdivision/Plat Name/Short Plat Number
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Assessor Parcel Number
Lot
Block
Plat Number
Pertinent File Numbers
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Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings Lot Size (Sq. Ft./ Acre) Depth
Frontage
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Left Setback r Right Setback
Rear Setback
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R/ W Width
Additional Information
Square Footage
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Number of Bedrooms
Building Technician
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Group
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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 agent to compile said application is true and correct.
Si nat r
Sig � _Date
Cond.
Appr Tied Approval
Hold
Environmental Health Application M
W. 1101 College
Room 200
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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
]:Phcne
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.
Si nat r
Sig � _Date