1986, 04-29 Permit App: 00010938 Relocate Residence(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
Project Number
Owner's Name II LAST riRST
Project Address (Street Name & umber)
£4S7- 4ti S, &►T) AVE
M1
Zip
44721
Applicant I Address
City State I Zip Phone
,42..L.z77 _f/es-
Business Phone
( )
Contractor/Agent J
City
State Zip
Contact
Architect /Engineer
City
License Number (Requiied)
G ?(£ 9<.
State 1 Zip
1 _
Contact
Lender
City
Address
Phone
3usiness Phone
(
Address
Phone
Business Phone
Address
Phone
(
Block
Plat Number
Comp. Plan
Census Tract
Lot Size (Sq. Ft./Acre)
Depth
J
Frontage
Right Setback
R/W Width
Type
`vN
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.
Signature
Date y 2 7 'd^-27
Approved
Cond.
Appprovrov al
Hold
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/ Environmental Health Application # 1� -- D #f
W. 1101 College
Room 200
6
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Planning/Zoning
N. 721 Jefferson
Engineers '
N. 811 Jefferson/� ��
/i .� T/
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.
Signature
Date y 2 7 'd^-27
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