1985, 12-31 Permit App: 00009286 Residence(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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Owner's Name LAST FIRST MI
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Project Address (Street Name & Number) Zip
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Applicant
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Address
City
State
Zip
Phone
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Business Phone
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Contractor /Agent
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Address
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City
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State
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Zip
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Phone
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License Number (Required)
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Business Phone
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Architect/Engineer
Address
City
State
Zip
Phone
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Contact
Business Phone
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Lender
Address
City
State
Zip
Phone
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Deecrlbe Work
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Subdivision/ Plat,Namp/Short Plat Number / 1
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Assessor. Parcel Number -
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Lot
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Block
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Plat Number
Pertinent File NumbersZone�j
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Comp. Plan
Census Tract
Number of Dwelling Units
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Number of Buildings
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Lot Size (Sq. Ft./Acre)
Depth
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Frontage
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Front Setback
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Left Setback
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Right Setback
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Rear Setback
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Additional InformationSquare
I DEPARTMENT USE
Footage •
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Date
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Group
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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 is true, correct, legal, and binding.
Owner's Signature
Date /2'/3/��j
Approved
Cond.
Approval
Hold
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Planning/Zoning
N. 721 Jefferson
Permit Number
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Engineers s1
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Utilities
N. 811 Jefferson
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Plan Review/Fire Prevention
N. 811 Jefferson
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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
Date /2'/3/��j
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