1986, 04-24 Permit App: 00010686 Repair Fire Damage - 4
(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 USEer C
Project Numb
Owner's NameLAST
E- FIRST MI
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Project Address(Street Name S.Number) / el-
Zip
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Applicant Address
City State j Zip Phone
( )
Business Phone
( )
Contractor/Agent Address
/(//0 i— Gomes f Co/7 ...511 .'e--A0',7 i �,O.,17�i'//??Y �//��411
City State Zip Phone
ct License Number(Required) Business Phone
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Architect/Engineer Address
City State IZip Phone
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Contact Business Phone
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Lender
Address
City State I Zip Phone
Describe Work _ • Rest /
Comm.yij:R -c,ve\r \. :ca. - i,4 RL t"— -"�est-DcA c-
Subdivision/Plat
Name/Short Plat Number
( (?f ,r- ti: (i (64,0 e\cA=-t- i t C O4 t"i to/-' Y , .
Assessor Parcel Number • Lot Block Plat Number
Pertinent File Numbers Zone
Comp.Plan Census Tract
AC?��t
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 Square Footage
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0
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a
2
ca
0
u.
z
0
g
CO Number of Bedrooms
.-
ButtdjngTechnleftn Date. Jr' Group Type
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•
DEPARTMENTAL REVIEW
Cond.
Approval pprrovov al Hold
Environmental Health Application#
D W. 1101 College
Room 200
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