1986, 08-26 Permit App: 00012839 Garage(THIS IS NOT A 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 DEPARTMEfdrnL USE
Oaner's Name LAST FIRST. MI
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Project Address (Street Nam & Number) Zip
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Business Phone
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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
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
/f � /s �j/7
di /�/ S
;44-94
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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/CrItIcat Material/etc.)
Fast Track/Special Inspection Information
Protect 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
4{
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Show on Site Plan:
Additional Information:
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