1986, 02-18 Permit App: 00009725 Residence • (THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET I/`5 -
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 Ins
Owner's Name LAST FIRST MI
23/1C!-,c ECSC 7�,<• &----_-C- / V C
Project Address(Street Name&Number) Zip
Ki - 1301 s Ki ewoii(i CTT
Applicant Address
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City State ZiPhone
soo,�,�ti� (.-1/.4zp 992.7 1/ (sol) q22 - 7Z7o .
Business Phone
( ) �yv-dy c� '
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
/f Ha /76NA 01 ( )
Architect/Engineer eg/C�/ / ` Address
City State c r �OZip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
Describe Work Res. Comm.
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number (.____M Lot Block Plat Number
1(0 5 i 7 - A ' .‘ r6)14.1et) 4 1
Pertinent File Numbers Zone Comp.Plan Census Tract
C..•-
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
I ISI SS '
Front Setbac Left Setback.04
Right Setback 1 Rear Setback
RAN Width
Additional Information Square Footage
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m Number of Bedrooms
Building Technician Date Group Type
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DEPARTMENTAL REVIEW
Approved Cond. Hold
Approval
Environmental Health Application# if‘ '6
W. 1101 College
Room 200
eyfrpty—Vitti
14/
Planning/Zoning
N.721 Jefferson
Engineers ; i r i, 0--_�/ 41 8t/
A. N.811 Jefferso ✓�l��t ice- L -G - i,1/%'��i� 4
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Utilities
0 N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson / v'
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 appli -tion is true and correct.
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