1986, 06-13 Permit App: 00011569 Addition (THIS IS "—NOTA PERI�/1IT)
BUILDING PERMIT APPLICATI®lel 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 / 5
Project Number ! ,n
Owner's Name /cteLAST FIRST MI VJ
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Project Ad . - --:
dress(StreetName&Number) Zip
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Applicant _ - -- �Add:"(-}
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City— O Stats �� i zip �� Phone ���� r STS-- J• �CJ
Business Phone
( 1
Contrac /A ent Address
City State Zip Phone
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Contact License Number(Required) Business Phone
Architect/Engineer Address
/.......,
City State Lip Phone
( 1
Contact Business Phone
Lender
Address
City State Zip Phone
( 1
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A
Di T�d C,6 /` 1� i c ices./ Comm.
�' s l,ShottPj Umber
umber Lot Block Plat Number
r31 -� t� �5 /5 Cn
ile Nu nrbers Zone Comp.Plan Census Tract
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[ veliinits � Numberof Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
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/58 ith
Ltd Right Setback RearSetback RtW Width
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Square Footage
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GC
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m Number of Bedrooms
Date Group Type
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DEPARTMENTAL REVIEW
- Approval Hold
Environmental Health Application# —4‘0)--- / 3---6
W. 1101 College J
Room 200 —i, /,
/ _4.-""1 •i i limm..-- .
Tira 73COIrd-em,,) 3
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.)
0
❑ 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 compilesaid application is true and correct.
0 / 7 --8- -
Signature ` I. Date 6
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