1985, 03-11 Permit App: 00004550 MHf. (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)
Project #
's Name LAST
i
y FIRST MI
Project Address (Street Name & Number)
Zip
7-1
City
State
Subdivision/ Plat Name
071S
I
Assessor Parcel No.
Lot
Block
Plat #
/ 1
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1
12
/
Zone Act. #
Zone I { Census Tract
Dwelling #
No. of Buildings
Lot Size (Sq. Ft./ Acre)
Depth
`
Frontage
/��i %
Front SetbackLeft
_
Right
C, I
Rear
J
Applicant
Address
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City
State
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Zip
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Phone
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Business Phone
Contractor
Address
City
ate
Zip
Phone
Contact
License No. (Required)
Business Phone
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
( )
DBscribe Work
Res.
Comm.
Additional Information
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Square Footage
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Building
Group
Type
Technician
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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 __
L�
Approved
Cond.
Approval
Hold
Environmental Health Application # 2S'CJS�
W. 1101 College VICh
Room 2 0
Planning/Zoning
N. 721 Jefferson
Engineers '
N. 811 J ffers n
Utilities
N. 811 Jefferson L 7
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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