1986, 06-12 Permit App: 00011547 Detached Garage(THIS IS NOT A 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)
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Project Number
Owner's Name LAST FIRS -1 MI
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Project Address (Street Name & Number) Zip
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Applicant (.Address
34dic
City
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StaterZip
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Phone
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Business Phone
LAI') 72z 7yta
Contractor/Agent
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect/ Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
(
Lender
Address
City
State
Zip
Phone
( )
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Res.Comm.
Subdivision/Plat ame/Short IIPlat�ur��i
(OD PAS r
Assessor Parcel Number
64,55t/ -()So
Lot
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Block
7
Comp. Pian
Plat Number
Census Tract
Pertinent File Numbers .
Zone
214N
#(umber of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Setbadt�
Left Setback
Right Setback
Rear Setback
R/ W Width
AfddItioned IMormation
1 BUILDING INFORMATION
Square Footage
Number of Bedrooms
Tech °
.3 ^2
Date
Group
— /
Type
V NJ
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 f% - / " , it
Approved
Cond.
Approval
Hold
Environmental Health Application #
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W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
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 to compile said application is true and correct.
Signature
Date f% - / " , it