1986, 05-19 Permit App: 00011117 Enclose Porch(THIS IS NOT A 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)
J tiHUCU Mtit/-kJ HrIC roti IJ1-r'H1-1 I IVICIN I HL 1./JC
Project Number / / I -7
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Owner's Name LAST FIRST IE /
Mow,OS 4E4Ao/ s w
Project Address (Street Name & Number) Zip
M. 3 a A 6A40-t,�S' AQ VARiga4tiE Aso 990 3 7
.
Applicant
Address
City
State
Zip
Phone
(sO ) �g9 /Si 1
Business Phone
( )
Contractor/Agent
Address
City
State
Zip
Phone
( 1
Contact
License Number (Required)
Business Phone
( )
Architect /Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
(
vff
E (CH
Res.
Comm.
is IPlat Name!Short Plat Number
poet Num
/314
Lot
Block
Plat Number
ire Numbers
ZonA
Comp. Plan
Census Tract
ing`tl nits
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
� t `
Left Setback
Right Setback
Rear Setback
ay t sTr KV --
X -Itionaf:
RI W Width
i torriation
-rt am
1 BUILDING INFORMATION
Square Footage
2
• R
Number of Bedrooms
Group
Type
Date
DEPARTMENTAL REVIEW
I certify that I have examined this application and state that the information contained in it and submitted
by me or my age ryifi ompiie said application is true and correct.
Signature
Date
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
721 Jefferson
N.
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 age ryifi ompiie said application is true and correct.
Signature
Date