1986, 06-18 Permit App: 00011572 Siding(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)
Orl PitiC L1 Pin CPiO PinC FVn v C r - Pin I IVI CIV I "'AL LI0C
I / 1,,Project Number •
Owner's Name LAST FIRST M I
Project Address (Street Name & Number)pp/ %/% Zip /,
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Applicant
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!Address
City /
Stated° Zip
Phone
Business Phone
( 1
Contractor/Agent
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1 Address
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City
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State
Zip
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Phone
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Business Phone 2
Contact
License Number ibequaed)
Architect/Engineer /
Address
City
State j Zip
I
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
I Zip
Phone
( )
Describe
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Res.
Comm.
lsigniPiatN /Short Plat Num .y /
Assessor Parcel Number t
QC -4-1 ' \CtU`� J
Lot
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
FjcotSetback
Left Setback
Right Setback
Rear Setback
R/ W Width
Additional Information 67
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BUILDING INFORMATION
Square Footage
S
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Number of Bedrooms
Buil ding Technician
Date
Group
Type
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 to compile said application is true and correct.
Signature Date
Approved
Cond.
Approval
Hold
Environmental Health
W. 1101 College
Room 200
Application #
Planning/Zoning
N. 721 Jefferson
I
t
1
i
Engineers
N. 811 Jefferson
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 to compile said application is true and correct.
Signature Date