1985, 04-11 Permit App: 00004927 Residence+
33a a
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name (last) (first) (m) r Department Use Only
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2 Project Address (not Mailing Address) ar Road Name Space Zip
3 6, a 2 S I e-7
3 City/Community State
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Subdivision/Plat Name
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4 Assessor Parcel No.
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Lot
* S
Block
* * * DEPARTMENT USE ONLY * * *
4 5 SIc Code
Zone Act. 9
Zone
Project No.
9 n
6 Dwell9
1
No. of Buildings
Sq. Ft./Acre
Depth
13�f4
Frontage
7 Set Back -Front
(L)S-1
(R)S-2
Rear
Census Tract
Module No.
17,
16 Architect Firm Name
Street Address C./
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contract Firm Name
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Street Address
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Zip
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City
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State,, 11
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Phone
( ) 3-11--0 =2 5--y
Contact Person ,
X.e;�.
License No.
K 1<C0., r !sq/3,v
Phoneif different than above
( )
8 Owner/Agent (if different than 91 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
'Bldg
Other (YIN)
SEPA Exempt (Y/N)
Date
' 15 Type Work r
❑ Fire
❑ MH
❑ Demo
V New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
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10 Applicant Name ,,
cf1. r..-.! Q CO t" 7%. e...14 !r
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact PersonP�
if different than above
).
Additional Information
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DEPARTMENT APPROVALS
•
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application
This is nota Permit
•
•
Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
"
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1 Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration /addition
Room 200 ❑ Additional structure;
APPLICATION #
Conditions/Comments. .3E1ti%>✓ e_
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments*
J
Engineers: 0 Commercial; 0 - -sidential; 0 Flood Plain;
N. 811 Jefferson❑ drainage P. new access/approach; 0 fence;
'1
0 road improvements
Conditions/Comments•/V'�' Llva
�'�!
U
Utilities:
N.811 Jefferson
Conditions/Comments.
--
Other:
---
ors
I
Plan Exam
/y!rI 2 6.3
Fire Prev.
Conditions/Comments.
Project Representative Telephone
Agencies Performing Special Inspection:
1
II nformati
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
"I EXCEL"
MARK OF EXCELLENCE
BRICK
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Date: --�
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Dli/i • I.3.I. HEAD OFFICE • P.O. BOX 70, MEDICINE HAT, ALBERTA T1A 7E7 PHONE: AREA CODE 403-526.590:
SALES OFFICES: VANCOUVER (604) 270-8904
KELOWNA (604) 769-6325
EDMONTON (403)483.5159 CALGARY (403) 276812E
HELENA (406)442-8123
WINNIPEG (204) 943-9065
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