1985, 11-17 Permit App: 00008142 Fire Damage Repair(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)
ie7 `°
SHADED AREAS ARE FOR DEPARTMENTAL USE
Owner's Name LAST FIRST
Pr-oject Address (Street Name & N mber)
2//8 ' i r9II.koda
MI
Zip
Applicant
/be
State •
to
City
Address
7 et56 f'r
Zip
95c
Phone
Business Phone
(S )L53 I0
Contractor/Agent
City
SAF -(145 QPPL ,CAT
State
Address
Zip
Phone
Contact
Architect/Engineer
License Number (Required)
a �3 0/
Address
Business Phone
a7 ,3 /
City
Contact
Lender
City
State
Zip
Phone
Business Phone
Address
DEPARTMENTAL REVIEW
I certify that I have examined this
by me or my agent t2,«. mpile said
Signature ofie /6�
Iication and state that the information contained in it and submitted
on is true and correct.
Date /
Approved
Cond.
Approval
Hold
Environmental Health Application #
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
by me or my agent t2,«. mpile said
Signature ofie /6�
Iication and state that the information contained in it and submitted
on is true and correct.
Date /