1985, 11-15 Permit App: 00008781 Residence ? (THIS IS NOT A 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 1 Project Number g78(
Owner's Name LAST FIRST MI
Foht ,v 5orc" ,1eA- (e._ Ge/
Project Address(Street Name&Number) _.... Zip i.
N • 1.302— S K!P14),0a .� - - - -
Applicant Address e3 e'
City State Zip Phone _
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Business Phone
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Contractor/Agent Address
City State Zip Phone
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Contact License Number(Required) Business Phone
( )
Architect/Engineer Address 3
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City / State Zip Phone
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Con t Business Phone
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Lender Address
City State Zip Phone
( )
�t4tor' a- Res Comm.
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" �1t t'4` Pe)4 Block
Facet Numbe a. LPlat Number
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P��tFile°Nirimbers Zone -Comp.Phan. Census Tract
t ftrtber of Gittattlog Chats - Num ber of Bulld iin s t (Sq.Fti/Acre) Depth Frontage t
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)fit babaLeft Setback "( Right Setback, I" Rear Setback Rt W Width
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tr rxiation Square Footage
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DEPARTMENTAL REVIEW
Approved CHold
Approval
leEnvironmental Health Application# I 4.
W.1101 College
Room 200 '
Planning/Zoning
❑ N.721 Jefferson
Engineers
A i X M pl
N.811 Jefferson /" /`t
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention /i--/4
-<
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
o 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.
Signature` JC / / �, Date �7 J � �-
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