1986, 06-20 Permit App: 00011864 Residence;THIS IS NOTA PERMIT)
se,BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERS-T'AND
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
—ADEM AREAS AMC' FOR DEPART -"ENT L S --
S A U E
Project Number
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FIRST MI
Project Address (Street Name & Number)
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Address
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City State
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Business Phone
Contractor/Agent
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Contact f License Number (Re(juired) Business Phone
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Architect I Engineer `
Address
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City Statel_ip
Phone
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Contact
Business Phone
Lender r
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Zip hone
Describelitork ;
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Lot Lot
Block
Plat Number
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Comp. Plan
Census Tract
Aumber,# _"ling units Number of Buildings
Lot Size (Sq.Ft./Acre)
Depth ji i
Frontage t
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Left -Setback
Lit Setback
Right Setback t
Rear Setback
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R/ W Width
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Square Footage
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Number of Bedrooms
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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
2G�n Date
-C-�
Approved
Cond.
Approval
Hold
Environmental Health Application M
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers (O d
N. 811 Je ferson
Utilities
N. 811 Jefferson
Plan Review/ Fire Prevention �3
N. 811 Jefferson
Other (SEPA/Crltkal 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
2G�n Date
-C-�
S&AL15-