1985, 08-22 Permit App: 00007058 Remodel(THIS IS NOT A 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 MI
Project Address (Street Name & Number)
/� /4/5"/o /2/?.2-L oA/
Zip
9 YC,?2
Applicant
Address
City
State
Zip
Phone
Business Phone
( )
Contractor/Agent
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
{ )
Architect /Engineer
Address
City
State 1 Zip
Phone
Contact
Business Phone
Lender
Address
City
State I Zip
Phone
SutxfM dent to Name1B
U
Assessor Parcel Number
14 D740
fiat Numbet s
Lot
Block
Plat Number
Pertinent File Numbers
Number of Dwelling Units,
Number of Buildings
Zone cis
Comp.: Plan
Census Tract
ft!
Lett Setback
Right Set
Building Tpchniclan Date j
DEPARTMENT, U
Group Type
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health
W. 1101 College
Room 200
Permit Number
Planning/Zoning
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
Permit Number
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 is true, correct, legal, and binding.
Owner's Signature _ _ / .V ->4F Date