1986, 07-08 Permit App: 00012003 Reside, Reroof(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)
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Project Number 1_..Z�`r',
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Owner's Name LAST FIRST MI
Project Address (Street Name & Number) Zip
C .s'S'd Z S,,1T 99•Z i;
Applicant
J/ iriOS ,L A/AR111 ii
Address
k' SG .ZC ShA?TA
City
570 n ti.A h F
State
%A
Zip
7 ?.2 I2
Phone
( 1 3- 3 G/ / "- ye 4 0
Business Phone
( )
Contractor/Agent
Add ess
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect /Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State I Zip
Phone
(
ADr i�work
.RO a-.. Seder°z ( —SiCC J AL sarogAGE
Res.
[ plat Name/ rt Plat Number
/ eoLE--1-ToceA) OF
Assessor_ Parcel Number Lot
x/53 r — b, r2 I / 3
Block
2�
Plat Number
Pertinent File Numbers 1 Zone��/J''��
Pre''
Comp. Plan
Census Tract
Number of- Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
775 )
Depth
Frontage
Front Setback
Left Setback
Right Setback
Rear Setback
R/W Width
Additional Information
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BUILDING INFORMATION
Square Footage
Number of Bedrooms
BuildingTechnician
Date
Group
Type
DEPARTMENTAL REVIEW
I certify that 1 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.
Signatur/29244.
Date ?' 6G
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that 1 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.
Signatur/29244.
Date ?' 6G