1985, 12-04 Permit App: 00008515 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
Project Number
Owner's Name
LAST
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FIRST
MI
Project Address (Street Name & Number)
Si 3/g'
5S'ra
Zip
_
Applicant
Contractor/Agent
City
State
Contact
Architect/Engineer
City
Phone (�
Business Phone
(„S'o
Address
Zip
License umber (Required)
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State
Zip
Phone
Business Phone
( )
Address
Contact
Phone
Business 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, legal, and binding.
Owner's Signature � y � /�L; �iz��_ Date fo/.go/"' j" • •
Approved
pp
Apprrovov al
Hold
Environmental Health Permit Number
kVA
W. 1101 College
Room 200 ?'OE 7E(...06-1?
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson ,
/ 4-
Utilities
N. 811 Jefferson
I
Plan Review/ Fire Prevention
N. 811 Jefferson
t(d'
14"
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 � y � /�L; �iz��_ Date fo/.go/"' j" • •
40,
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