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1986, 11-10 Permit App: 00014185 Addition y - , (THIS IS NOTA PERMIT) r ~'� 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 1)y>/' . t` e / /7 -/:?1‘.• Project Address(Street Name&Number) Zip /O& l;/(-) r ( ;/, ,-),-1-'_/) Applicant Address l City State Zip Phone ( ) Business Phone ( ) Contractor/Ag t Addres if C5VUCF-77 / /_A,c, ` a 4_,:t- /V2 2____ City State Zip Phone oK11,v _ 7 9 z/ z/ ( ) q2.7--G 2-7 2..— Contact License Nugiber(Required) Business Phone Ai eel f -- ,QC ►C:r-QQ 17 ( col) 9a7-ze2-/ Architect/Engineer Address City State Zip Phone ( ) Contact Business Phone ( ) Lender Address City State Zip Phone ( ) r Ly/� s Res. Comm. �"'`. G' �f /,'�>,�/,�j !/Or. ( / ,Z/ 2-7/�V e, C'/fid,Le. ate'. bdivision/Plat Name/Short Plat Number ./) r. w: / 0/1/47:r_)/6) . ..F. : -f lir•k('.;` 112Ac7-s Assessor Parcel Nri"'r (,� Lot Block , Plat Number I r ` Pertinent File Numbers Zone Comp.Plan Census Tract Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage I• O Front Setback Left Setback Right Setback Rear Setback R/W Width t Additional Information Square Footage ///""" flip- A _ Z 0 I a a e 0 LL. Z_ 0 Z 0 J_ 5 m Number of Bedrooms Building Technician Date Group Type F ,3 \, N r • 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 ._ 1 . icit • I i I . I O 0 4 • • i • 1' /I/10 , 1 ,y/61-1-1 / r 111 , E I 1r , lAtir I ' , _1 i IM • 1 I ' • I � i N l otD - -It - - I • o I. -� . NV I Q O . , • ' I It ,))) • I; 1 • \`. , #3)/ otd• itP1/4., \ss,, fp ( 11 . k • , ('`). - • . . . .. . ,, : j rer wd. • I�' I Ok p . e. , 1. I aL fi Ileac I . . 1 eek 6,--fw!st .. . .. . 1 • .. . , . . i 1 • .,. . I . . • . . . . 1 • 1• . 1 . I . .4 •