1986, 04-02 Permit App: 00010290 Relocate Residence(THIS !S NOTA PERMIT)
BUILDING PERMIT APPLicATioN WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
Owner's Name
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Address (Street Name & Number)
LAST
L
Project
LAk)
2910 ls
Phone
Zip
20..(c2
S-oci 2:72- I
Business Phone
5:0
umber
Depth De ^"-
Right Setback Rear,SethitdcSquare Foc
,.„
Frontage
S. 5
Riwvvidtt
-44,a
Sedroorns
•
DEPARTMENTAL REVIEW
I certify that 1 have examined this application and state that the information contained in it and submitted
by me or my ag/3nt to compile said application is true and correct.
DateY 3()(
Approved
Cond.
Approval
Hold
Environmental Health Application #
/
r -5-"/T //
I>
g""iv
W. 1101
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers q yJ
N. 811 Jefferson 7/ y "
�i3��
AQ
'
l�
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 1 have examined this application and state that the information contained in it and submitted
by me or my ag/3nt to compile said application is true and correct.
DateY 3()(