1986, 01-24 Permit App: 00009719 Duplex(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)
Jrn M LJCLJ /111CMJ /A nm r'Vr1 UC r Yin I WI CIV I NL IJJC
P1 t9
Owner's Name LAST FIRST MI
e `( ��• F
�� �P /IcL,' I d J,
Project Address (Street Name & Number) Zio
Applicant
�A1�-!>�
Atldress
52/ �1/oRe.Lrnia Off'
City
Li r3 PrY LAKE.
State
L1J4
Zip
<<leIC>
Phone
( )
Business Phone
( 1
Contractor/Agent
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( 1
Architect/ Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
I )
Lender
Add ess
City
State
Zip
Phone
Describe Work`��►sJ l
T- pJ PL -E.)‹.. ,\t CNE-- oN J Or.) B�rn
Res. /
✓/
Comm.
Subdivision/Plat Name/Short Plat Number ,.
�LL L' C , I 0 - 06, 6.
P Lti I
Assessor Parcel Number
) <4 54 3 .- 92io C.fbr-1-1or)
Lot
Block
Plat Number
Pertinent File Numbers
Zone
P' _
Comp Plan
Census Traci
Number of Dwelling Units
Number of Buildings
I
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Front Setback j
')Jv
Left Setback (
5
Right Setback
Rear Setback ,
2
RIW Widthf
Additional Information
SP L-Ihru ( PF icy - S 5-.6 =
IBUILDING INFORMATION
Square Footage
x40.-= jeoo 4
Bp..rloc
S t O-CMuaF
i
1-1N(>
o.
I l 70 2- E . m pi -Li — P( fNT Lo cinr.
4k P>G •1 WV.Ilier ew % SIT< —g '4. Z4e6.
t12.5?)
Number of Bedrooms
Building Technician
-JN M-
Date
1_2-+-8&
Group
2 -5
Type
'\f
Environmental Health
W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Application ,#
Approved
Cond.
Approval
Hold
Planning/Zoning
❑ N. 721 Jefferson
CE-fo-8(0 `C
Engineers
N. 811 Jefferson
Utilities
O 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 to compile said application Is true and correct.
Signature "'/1-'ii(i4e-C2 '"/--- Date / `� O" RC
t• i/
(APoUCAlION NO. CC /D re5)6 G
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/hence SQQ urn /55.5o zc/, 792ce cothnu/ny'�ri7t/
392.00 f'cct fo `/;e .tbnvr or 8EG/NN/NG.
EXCEPT J` QSFL '0" &nil Excerr Main Aue-.
AAV EXCEPT 71hZ S,39?•00 At" Settrel of ,A.RCEL 77"
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