1986, 04-11 Permit App: 00010442 Relocate Barn Foundation (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
Project Number -
Owner's Name 1 LAST FIRST MI
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Zip
Project Address(Street Name&Number)
Applicant Address
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City State Zip Phone
Business Phone
--- Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City ' State Zip Phone
( )
Contact Business Phone
Lender Address
City State Zip Phone
( )
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DEPARTMENTAL REVIEW
Approved Hold
Approval
Environmental Health Application#
❑ W.1101 College
Room 200
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 agent to compile said application is true and correct.
Signature Date / ` "/ /
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