1986, 10-20 Permit App: 00013727 Remodel(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 NameLAST FIRSTMI
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Project Address (Street Name & Number) Zip
- AL—VA \--2_ C._\ ( _ i
Applicant -Address
City
State
Zip
Phone -(N \Z 06
Business Phone
( )
Contractor /Agent
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect / Engineer
Address
City
State I Zip
I
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
(
Describe Work
Li I 1
Res.
Comm.
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number
Lot
Block
Plat Number '
Pertinent File Numbers
Zone
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
BUILDING INFORMATION
Square Footage
ri y
Number of Bedrooms
Suliding Technician
Date
Group
Type
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health
❑ W. 1101 College
Room 200
Application #
Planning/Zoning
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
Utilities
❑ N. 811 Jefferson
Pian Review/ Fire Prevention
❑ N. 811 Jefferson
0
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