1986, 08-12 Permit App: 00012702 Shopor lt
(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 i r -76.2—
Owner's NameLAST
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FIRST
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Project Address (Street Name & Num
1.17
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101E k_ . \P- 44� A I'31037
Applica
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Address
.1-5- 17 1N115NI —fi C_ `
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State
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Phone () q ���
Business Phone
Contractor /Agent,..._ �
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Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect /Engineer
SELV-
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( 1
Lender
..--------
rteCity
Address
City
State
Zip
Phone
(
Describe Work
1_17; 1
, p
Res.
Comm.
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number
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Lot
5
Block
frz—
Plat Number
Pertinent File Numbers
oritaisu 8
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
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I BUILDING INFORMATION I
Square Footage
% 0
Number of Bedrooms
Building Technician
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Date
/ �� `'
Group{
A"I -
Type
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Environmental Health
W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Application #
Approv d
Cond.
Approval
Hold
Planning/Zoning
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
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 is true and correct.
Signature Date
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