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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 Asia