1986, 07-09 Permit App: 00012051 Residence(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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Owner's Name L LAST FIRST MI
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Project Address (Street Name & Number) Zip
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Applicant
tet`c�cIi-e- L(.-er-ka---
Address
12)1S E 263-1-
CityState
5pLLy...
gyre,
Zip
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Phone
1 ) ?TZY-9-/08
Business Phone
( ) 92.C.—o6c2.
Contractor/Agent
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Add
ess
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City
Spc,)ccr i
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State
V'.,(�
Zip
99 2._/6
Phone
1 ) c2_crc 60 2
Contact
-
License Number (Required)
LEni cc. 1 2 3 J3
Business Phone
i ) 42.0 — 0 C C t
Architect/Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
I Zip
Phone '
Describe Work t ..,�,,,• .., ,.:Ytiy..t:......- 'r ti,v ra...,:ie pf. 4w; .- .. ..
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•SubdivisionlPlat Name/Short Plat Number,.. '-A .. i :.'+z'z ... - .:. :'->'-"._*f'4µ'. t', ..t€x..;,f' .'}_�" ,. '.rx-•00 --44. x
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:Assessor Parcel Number. .-y_=,•i
• 12:33-141:— oS.
.Lot�:
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44 0•I
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Plat Number ` t t
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Pertinent Fila Numbers c , - . -' s° : �"r "-: �-'M1
' Zon "./.•_•;',.): -
:Comp. Plan' Th$
Census Tract'' .. -. ^•
- Numberot Dwelling Units _
., 1..1 - :1 )V'
Number of Bu1iltlings-,.';-t _
..- a. 4.44 4r:',.i,'< M1i,-
Lot Slze(Sq. Ft./Acre)-
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Oepth,„ j. _
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Frontage•
:. _cm. ; '_ _
Front Setback t •
'' i 30
Lett Setback' 0 - -t _; a
- ''1,
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Right Setback -;�;:: +
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.. '.5 .i.? ;:
Rear Setback i?.. t• -
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R/W Width:, t. -
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Additional Information r . _. t, - .... ., --
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Square(Footage.
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N.um.ber•of Betlr•coo-mi
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,Building Technician-
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Group '
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Type•' -.
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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
Approved
Cond. Approval
Hold
—67/'�
Environmental Health Application #
L
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W. 1101 College
Room 200 - ---
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Wt,e/
7
Planning/Zoning
N. 721 Jefferson
Engineers 4_r3 7C
N. 811 Jefferson ,%L
Utilities
N. 811 Jefferson .
Plan Review/Fire Prevention
N.811 Jefferson
"/"76 -,i -a
17-47
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Intormation
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
1
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