1985, 07-30 Permit App: 00006622 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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
lProject Number
Owner's' Name LAST FIRST MI
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C iS// fv/ 5e/774 -i• S `s•� , //-
Project Address (Street Name & Number)
7(i / . j.i..rf
Zip
Applicant
Address
c.iy.x /37/7
City
State
Zip
Phone
(Ci2a) -- 2 Z
Business Phone
Contractor /Agent
Address
City
State
Zip
Phone
Contact
License Number (Required)
Y" `Z i b /N G_.
Business Phone
( )
Architect/Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
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, leg
Owner's Signature
d binding.
Approved
pp
Apprrovov al
Hold
Environmental Health Permit Number Vc-1,°� s7,37__�0
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W. 1101 College
Room 200
"fr-t --1.1077/ lb-sf—X0-4.-
Planning/Zoning
N. 721 Jefferson
Permit Number C ' 2 -
./
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
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, leg
Owner's Signature
d binding.
I ULt. tl[At. LS1A[ESERVICE
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4131XTERPRISES
QUALITY CONSTRU' TION • l AN[) IIF V1 t ()PM( 141 e':
ILL 42'? 2700 • N 1506 PINES ROA❑ • SP!)Y.PNI Y: n a"%04
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QUALITY CONSTRUCTION • LAND DEVELOPMENT
TEL 422 2200. • YV. f506 PINES ROAD SPd:KAP E, WA "4-246
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