1985, 09-25 Permit App: 00007698 Garage(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
IProject Number
Owner's Name ».ST IRST MI
�., L' o(Z4)T- H
Project Address (Street Name & Number)
Applicant
Zip
rir 2 fit,( Cm 2 el ec isdAe 2 rz� (AM , 9 9 4 l $
Address
City State Zip Phone (� Q ttQ l'1W
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
Add ess
City
Describe Work.
State I Zip
Oadl 24`i4:3Zf
Subdivision/ PIaNamelShort Plat Number
fZ(3�N )flora o 6712 e j}�tYiZ
Assessor Parcel Number
Pertinent File Numbers
Phone
Comm.
Zone i�
Block
Comp. Plan
Plat Number
Census Tract
Front Setback,
Number of Buildings
Left Setback
Right Setback_.
Rear Setback
Frontage'.
Additional Information
$. Building Technician
LI m
Date
/2_c hr
DEPARTMENT USE
Square Footage.
Group
M —I
Type :..,_
DEPARTMENTAL REVIEW
Environmental Health
W. 1101 College
Room 200
Permit Number
Approved
9,
Cond.
Approval
Hold
Planning/Zoning
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
Permit Number
Utilities
❑ N. 811 Jefferson
Plan Review/Fire Prevention
❑ N. 811 Jefferson
Other (SEPA/ Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative LPhone
Address
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent is true, correct, legal. and binding.
Owners Signature Date