1986, 05-12 Permit App: 00010981 Shop(THIS IS NOT A PERMIT) - -i
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
I,
Applicant
Address
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
( )
t
Describe Work
Res. j-'
Comm.
Subdivision/ Plat Name/Short Plat Number
Assessor Parcel Number
r
Lot
Block
Plat Number
Pertinent File Numbers
Zone //� (�
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Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft. IAcre)
Depth
Frontage
Front Setback
Left Setback
Right Setback/
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Rear Setback
?
R/ W Width
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Additional Information
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Square Footage
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Lft
Q
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Z_
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Number of Bedrooms
Building Technician
Date
Group
Type
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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.
Signature
Date
Approved
Cond.
Approval
Hold
Environmental Health Application M
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson L 7
Pian 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