1984, 11-18 Permit App: 00008991 Residence(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
Owner's Name LAST
uk
Project Address (Street Name & Number)
EAST � 2c
FIRST
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MI
Zip
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Address
Applicant
Vt 64A, E s C -1 • co -
(- (-S3 13 -
City
1Ac
State
W14
Zip
WO3F,
Phone
(
Business Phone
) 448-Zj3s
Contractor/Agent
v(te_t,t—
CCA
State
Lti
City
U�
ContactLo
Add ess
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Zip
990 3
Phone
License Number (Required)
V( 52/ 1c ►—
Address
1'J- at,,o�
Architect/En
Business Phone
City
oat e -
State
Contact
( )
Zi Phone
Business Phone
V(S«_
Lende6"/ iC. 7(1A 1
City
Address
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 a_ ent to compile said application is true and correct.
Signature
Date 11
Appro° :-•�.
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Hold
3
Environmental Health Application # 3 -/ 13
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W. 1101 College,
Room 200
--0e/;;°7 ‘-e)-d
*—,/,,0-72-,./7/74
.
Planning/Zoning
N. 721 Jefferson
-� /
Engineers F7//
N. 811 Jefferson Ly 4--i
!� i 2r5-
Utilities
N. 811 Jefferson
I
Pian Review/Fire Prevention
N. 811 Jefferson
/1-3-S 3
/-e'a
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 a_ ent to compile said application is true and correct.
Signature
Date 11
4
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SCAIF