1985, 11-04 Permit App: 00008502 Garage (THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET /d j. 5�
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
Fr€eet Ptemeer
Owner's Name LAST FIRST M1
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Project Address(Street Name8,Number) Zip
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Applicant Address
City State Zip Phone
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Business Phone
( )
Co`,ny�for/Agent Add(@sak L f o 94 2
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City �� State �� Zip 9 Phone ( ) � ' O�
Contact License Number(Required) Business Phone
pAal
Ar tlEngineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
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mat Number
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ingTechnict$rt "r ' %° ` ts... ' ,g Group Type
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DEPARTMENTAL REVIEW
Cond.
Approved Approval
f •
Approval
Environmental Health Application# �0 `
❑ W.1101 College`"' �� I
Room 200 No 41
0
Planning/Zoning
O N.721 Jefferson -
Engineers
❑ N.811 Jefferson
Utilities I
0 N.811 Jefferson
Plan Review/Fire Prevention
o N.811 Jefferson
Other(SEPA/Critical Material/etc.)
O 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.
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Signature �� Date
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