1986, 01-31 Permit App: 00009556 MH(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
Owner's Name
Project Address (Street Name & Number)
LAST
1)14/711
FIRST MI
O 5/‘ / `"5 .4eta7,'
Applicant
-64V/e/'- CC?' /C) --67.-‘;t7
State
LZ -141
City
_.,5)%2174,
Address
Zip
/ 9 /S?r, jr/r 'r //
Phone /
Business Phone
( )
Contractor/Agent
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
( )
Architect/ Engineer
Address
City
Contact
Lender
State
Zip
Phone
Business Phone
( )
Address
City State Zip 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 to compile said application is true and correct.
Signature Date
Cond.
Approved Approval
Hold
Environmental Health Application #
`
(/ 4 0 //n��
jl f
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
!37
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