1985, 11-12 Permit App: 00008736 MH(I
(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)
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Lo)ect Number
Owner's Name LAST FIRST MI
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/12 .2.1/1/- ,912 Fiee
Project Address (Street Name & Number) Zi
/Vogl tf /028 toC',usT Pa 91206
Applicant 1.A,/ddress
XifgEfi^ C%- %%AL rAid- id ',/ tr, Ar/c 40G//J71.
CityZip
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Le/47 .
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Phone
v1 ) ,2‘. 7*1i7
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
l )
Lender
J' t-1772
Address
City
State
Zip
Phone
Describe Work/,
OoueLE- GUIDE (---C3x5(0) d B Ili
Res. /
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Comm,
Subdivision/Plat me/ Short Plat Number
sem- Onx
en-PAlLa ,!'
Assessor Parcel Number
>-751%2- >345
Lot
Block
Plat Number
Pertinent File Numbers
V e - ii- ett
Zone
A0.su s
Comp. Plan
Census Tract
Number of Dwelling Units
/
Number of Buildings
2-
Lot Size (Sq_Ft,/Acre)
Depth
'50
Frontage
75
Front Setback
Left Setback
Right Setback
Rear Setback
R/W Width
Additional Information
I BUILDING INFORMATION
Square Footage
Number of Bedrooms
BuildingTech
Date
>>-12-85
Group
2-5
Type
vN+
171
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 co s ile sa application is true ji correct.
Signature
Date
Approved
Cond.Hold
Approval
Environmental Health Application n
W.Roo1101 ollege
m College
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Planning/Zoning
N. 721 Jefferson
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Won,
Engineers /
N.811 Jefferson ,. �� -�--
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741 t - r
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Ofuti�2o
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lities
Utilities
N.811 Jefferson
Plan Review/Flre Prevention
N. 811 Jefferson
Other (SEPA/CrItIcal Materlal/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 co s ile sa application is true ji correct.
Signature
Date
t_,
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