1986, 06-23 Permit App: 00011754 Addition(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)
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Project Number / /
Owner's Name LAST dip FI RST MI
Project Address (Street Name 8 ber) Zip
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Applicant
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Address
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City /
State i Zip
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Phone
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Business Phone
( )
Contractor/Agent
Address
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City
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State I Zip
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Phone
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...,,..License
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Number (Required)
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Business Phone
( )
• c ' ect/Engineer
Address
City
State I Zip
1
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Il
I Zip
Phone
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es
Describe Work /,/�/
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Res.
Comm.
Subdivision/Plat Name/Short Plat Number
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Assessor Parcel Number e
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Lot
/
Block
2-
Plat Number
Pertinent File Numbers
Zone
M-SCie-
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Front Setback
Left Setback
Right Setback
Rear Setback
R/ W Width
Additional Information
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BUILDING INFORMATION
Square Footage
Number of Bedrooms
Building Technician
Date
Groupj
Type N {
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.
Cond.
Approve
Hold
Hold
Environmental Health Application # �
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W. 1101 College
Room 200
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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.
_1