1986, 11-10 Permit App: 00014185 Addition y - ,
(THIS IS NOTA PERMIT)
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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
I Project Number
Owner&Name LAST FIRST MI
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Project Address(Street Name&Number) Zip
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Applicant Address
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City State Zip Phone
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Business Phone
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Contractor/Ag t Addres
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City State Zip Phone
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Contact License Nugiber(Required) Business Phone
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Architect/Engineer Address
City State Zip Phone
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Contact Business Phone
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Lender Address
City State Zip Phone
( )
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s Res. Comm.
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bdivision/Plat Name/Short Plat Number ./) r.
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Assessor Parcel Nri"'r (,� Lot Block , Plat Number
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` Pertinent File Numbers Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
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Front Setback Left Setback Right Setback Rear Setback R/W Width
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Additional Information Square Footage ///"""
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m Number of Bedrooms
Building Technician Date Group Type
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DEPARTMENTAL REVIEW
Approved Cond. Hold
Approval
Environmental Health Application# (�Gr� 9 U --`7-c=--n-
❑ W.1101 College �I-1 o C ('
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 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 Date
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