1986, 07-31 Permit App: 00012721 Residence(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
Owner's Name
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
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Project Address (Street Name & Number)
LAST
/t/C
FIRST MI
0 `7 2-
Applicant
Zip
Address
State
Phone
Business Phone
Contractor/Agent
`?i ' S 2 ,4S S the //l'
State
Address
Contact
c 101 X'
Zip
Phone
722 -odd2_
License Number (Required)
CCS .S 1' ?- 4.7‘1' /%%6
Architect/ Engineer
Business Phone
Address
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City State Zip
Contact
Lender
City State Zip
Phone
Business Phone
Address
Phone
Lot Size (Sq. Ft./Acre):
Frontage
wetle
Group
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.
Date
Approved
pp
Apprrovov al
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers�/J t,
N. 811 Jefferson V/� d ' _r °2/
i 3 /! r
‘T
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
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R
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.
Date
LEGAL:
S.MILISSA
LO'(I ILOGIZ S"
I D I L O M I_ 411+.
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