1986, 04-30 Permit App: 00010782 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 -
Project Number
Owner's Name LAST
FIRST M I
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Project Address(Street Name&Number) Zip
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Applicant Address
City State Zip Phone
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Business Phone
( )
Contractor/Agent Address �+
City State Zip Phone
I
Contact License Number(Required) Business Phone
Architect/Engineer Address {
C
City I State 17_ip Phone
Contact Business Phone 1
1 1 a
Lender Address �� v
City State I Zip Phone
( ) I
Describe Work (s Res Comm.
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number Lot Block Plat Number
"7> —Cci 2 '1 2-7 7
Pertinent File Numbers Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
Z
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I-
2
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0
z
0
5
m Number of Bedrooms
Building Technician Date Group Type .
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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 #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Plan Revlew/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