1985, 11-12 Permit App: 00008688 Detached Garage • w
• (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 or86
iginal and your building plans to the Department of Building and Safety)
(C f SHADED AREAS ARE FOR DEPARTMENTAL USE
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Owner's Name LAST FIRST MI
Project Address(Street ame&Number) Zip
S /yi 0/f e •`�
Applicant(� ,y� • Address
City State Zip Phone
Business Phone
( )
Contractor/Agent ,s Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
Architect/Engineer
Address
City State Zip Phone
( )
Contact Business Phone
Lender Address
City State Zip Phone
( )
" ` des Comm.
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Part Ambet >.'r „a
Biock Peat Number
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ont v L ` A back Rear SetbackV�cv� R/W Width
tnfor�r7-1' Square Footage.
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o rooms
Number Bed
i Group Type
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DEPARTMENTAL REVIEW
.proved Cond. Hold
Approva
Environmental Health Application# /6�ni
W.1101 College #if/' A
Room 200 r • p' J
Room
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Planning/Zoning
❑ N.721 Jefferson
Engineers
0 N.811 Jefferson
Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson ,
Other(SEPA/Critical Material/etc.)
0
❑ Fast Track/Special inspection Information
i
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 _2( • 7f1 1....11/2.-e-A—c/- Date ///..3/(J