1986, 05-27 Permit App: 00011232 Remodel"(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
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prdjeMt Number
Owner's Name LAST FIRST
MI
Project Address (Street Name & Number)
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Applicant
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State
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zip
C9:1QLG‘ 19.20
Address
I 367 /1J--&
Phone
Contractor/Agent
(l2,)(e7/,4
Business Phone
( )
Address
State
Contact
Architect /Engineer
Phone
Business Phone
( )
Address
State
Contact
Lender
Phone
Business Phone
( )
Address
State
Phone
Block
Comp. Plan
Plat Number
Census Tract
Lot Size (Sq. Ft./Acre)
Right Setback
Frontage
R / W Width'
SquataPootage
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 1l
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Date S o-7 ~ t -'r"
47
Approved
Cond.
ApprovaF
Hold
' Environmental Health Application #
W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
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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 1l
/ 0.)Ji
Date S o-7 ~ t -'r"