1986, 06-24 Permit App: 00011933 Residence(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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number
Owner's Name LAST FIRST MI
Project Address (St ==t Name & Number)
/y3y 9V�xa
Applicant
State
1.41
Business Phone
(
Contractor/Agent
City
State
Address
Zip Phone
Contact
Architect/Engineer
License Number (Required)
Business Phone
Address
City
Contact
Lender
State
Zip Phone
City
Business Phone
(
Address
State
Zip
Phone
Rear Setback.
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 a.. , e and correct.
Signet
f
Date
_ Approved/
Cond.
Appprovrov al
Hold
Environmental Health Application #
W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
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Cd r 11-e' .. /q(‘I
f
Engineers �y� 3
N. 811 Jefferson 7'r l(
�/�
7
/ �!
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
(
I
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 a.. , e and correct.
Signet
f
Date
;
POSETY
1—eia_ TECIPRIS.E.
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