1986, 09-03 Permit App: 00012934 Addition • (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 k F oJectNumber !
t2,„93
Owner's Name LAST FIRST MI
PIC 0r) 1e7' �;9-icKey
Project Address(St eet Name&Number) Zip
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Applicant Address
City State Zip Phone
6 Po, 74- :ill 6u A , ( )
Business Phone
( )
Contractor/Agent Address
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City State Zip Phone
Contact License Number(Required) Business Phone
00 (-Ok)( ( 0f/Y6, fr- S DES(coca It, lc) S (c/t. 7) (2a2 2
Architect/Engineer n Address
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City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
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A Parcel Nutmbe >r ',1:''-x..--" Lot Block Plat Number
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inert File Numbers ZoneComp.Plan Census Tract
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Number of Dwelling UnitsNumber of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
. 4x ../ r. 1Io5co
tSetback Left:Setback Right Setback Rear Setback R/W Width
dditlonal information; Square Footage
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m Number of Bedrooms
,TidingTician Group Type
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DEPARTMENTAL REVIEW
Cond.
Approved Hold
11n J/(J' Approval
g Environmental Health Application M
W.1101 College ktAiov4LRoom 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
0 N.811 Jefferson
Plan Review/Fire Prevention yit
❑ 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 compile said application is true and correct.
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S g ature U`' _ Date
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