1986, 06-30 Permit App: 00011880 Residence Y (THIS IS NOT A 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
Project Number t I ES SO
Owner's Name f7 /,� LAST n FIRST MI
� ' 9 ii/P //ameJ r'J i ✓ /N6'
Project Address(Streeleflame&Number) Zip
/7/#.7 r. /f47/3f9A1 Y;)0°12 fief/ewe 91;;a‘
Applicant /J Address /
�B,.//Gjt/VI? /�rn e Qr✓/(7/w/P. Zip �, , Phone� f� 54 0��1�
City /�, _WA°ot,0 1r/ft qQ
Business Phone
( ) 90Po_ Q79i 2_
Contractor/Agentnn Addressd/
,,,,,A ,e,i/e/e ./Arri C. o/1--- ._140P.-1e City State Zip Phone
r7,4714l.G,p7t/✓ 99.// ( ) ,--- — �916,2__
Contact License Number(Required) i Business Phone
t .1e,✓ 6?A s /�..s2/.f/4' /$5 J r9 ( ) 9.2.)— 023/.2--
Architect
?9/.2—
Architect/Engineer �J 11 '81 Address
/J
City State Zip Phone
( ) 9,,10—.27) 2--
Contact Business Phone
I
,�Ar tr 6/F:4 �f ( ) 5>c,..=2- a9/ z.
Lender Address
City State Zip Phone
( )
Describe Work Res. ,,, Comm.
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number ? Lot Block I Plat Number
Pertinent Numbels Zone Comp.Plan Census Tract
tcJ�/7` C/C . '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 j 3 8 i 6
'OF 717 ?3(- )
Z -- 33G
E
ccZ
u. 6 : X72-i
z
_o
J
5
m Number of Bedrooms
Building Technician Date Grgup Type
•
DEPARTMENTAL REVIEW
Approved Cond. Hold
pp Approval
Environmental Health Application# ¶. �
W.1101 College k.4 ,n.,,.
Room 200 (Z,C�I�
Planning/Zoning
N.721 Jefferson24.
l�
Engineers .,.� t 4
AKI N.811 Jefferson 3S - �/
Utilities 7 /p(
❑ N.811 Jefferson ! a
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 ., - ._ 4r .et Date
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