1986, 07-15 Permit App: 00012114 Duplex•>
(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 �/ LAST FIRST MI
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Project Address (StreetetName S. Number),/ // p [� Zip
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Applicant.
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Address �
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City
State
Zip
Phone
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Business Phone
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Contractor/Agent����JJ��7
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Address
City
State
Zip
Phone
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Contact �-
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License Number (Required)
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Business Phone
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Architect/Engineer -
Address
City
State
Zip
Phone
Contact
Business Phone
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Lender
Address .
City
State
I Zip
Phone
( )
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Subdivision/ Plat Name/Short Plat Number„ •. •.r' ". t � - . -- -
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Assessor Parcel Number _ _ r` - _• -1 l-
Lot •,, �;F - - „
+Block ,
Plat Number ... •t
Pertinent File Numbers^•Y
Zone...?
Comp Plan' _ - -•
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CensusTract • -'---
Number of Dwelling Units
. Numbecof Buildings•.:,,, ..
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Lot Slee (Sq. FL/Acre) . .,Depth
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Frontaagge_.t.( . �.
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Front Setback -
30`
Left Setback'.
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Right Setpacckk{ . y`
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Rear Setback• ....:-•: .:
-
R/W Width --
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Additional Information ': " .%;. ..z.:2.,'
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;:: �},� � ^BUILDING�INFORMATION, ' • �„f;;
: Square Footage .
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Number of Bedrooms:: ' :, :•F : •:
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,Building Technician _.
'Date ..'�.
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.Group.
':Type N
Environmental Health
❑ W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Application #
Cond.
Approval
lark j
Approved
Hold
Planning/Zoning
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
%5
Utilities
❑ N. 811 Jefferson
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 i rue and correct.
Signature
Date
54 sic /h//6" ?LEX
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