1985, 08-02 Permit App: 00006669 Addition(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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
IProject Number
Owner's Name
LAST FIRST
MI
ED
Project Address (Street`Name & Number)
St `
1 V .iV�'� �1�,` V e ` Pc -
Address
lei c -
Applicant
Zip
cAck.0.-57
0.K`(\e- OxS 0.\:;i0 e.—
City
Ye( OAX:VQ—
State
Zip
gcke)3-7
Phone
($)1) 7c •
Business Phone
(soct 71-M-7
Contractor/A ent
SC\ (a
City I-State�
Address
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect/Engineer
Address
City
State I Zip
Phone
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
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 is true, correct, legal, and binding.
Owner's Signature Date
Approved
CpApproval
Hold
Environmental Health Permit Number
r;•�"J
\ �f, tek
W. 1101 College
200
_Room
1
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
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 is true, correct, legal, and binding.
Owner's Signature Date
Ci4 PoRT
o3 PR06RE55 P,,j).
P.ERIPI VIEW pF 1.07'RN1) LocPTIoN of NOUSE,WiT PROPOseq