1986, 03-25 Permit App: 00010212 Residence Addition(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)
Owner's Name
Project Address
Applicant
City
SHADED AREAS ARE FOR DEPARTMENTAL USE
LAST
FIRST
MI
Project Number
(Street Name & Number) Zip
1
State
•.dress
Y•
Zip Phone
Cont/Agent
City State
Architect/En
City
Contact
Lender„
r
Zip
)9•2o
License Number (Require
Business Phone
)
Address
GGP‘ 4,44e -
Phone
(0 9) S'3f JC 4'
Business Phone
(5. /7(/L QAddress ) c3 n3 Y
State
Zip Phone
Business Phone
)
Address
State
Phone
Lot Size (Sq. Ft./Acr
.1562_
42.
Right Setback m.
EX (57 7
Frontage
R/W Width
DEPARTMENTAL REVIEW
I certify that I have exam
by me or my agent t
catiot and state that the information contained in it and submitted
nd correct.
Date
Approved
CpApproval
Hold
Environmental Health Application #J
/,.
-,017-g•
"idtdi
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
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 exam
by me or my agent t
catiot and state that the information contained in it and submitted
nd correct.
Date
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