1986, 06-02 Permit App: 00011339 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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number
Owner's Name
Df loop
LAST
FIRST MI
Project Address (Street Name & Number)
6(zeeli) Oc(Zes
Zip
�19o/6
Applicant
rtry K ti
tate W
2eecR
Address
5-1)-N
Zip 9c' /
Phone J ) ^ 7 4'9 7
Business Phone
Contractor/Agent
Address
City
State
Z'',D Phone
Contact
License Number (Required)
Business Phone
Architect /Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
Work,'
off NIC,,
Res.
Comm
Assessor. Parcel Number
V
Lot
Block
Plat Number
Pertinent File Numbers
Number of Dwelling Units
Number of Buildings
Zone
Lot Size (Sq. Ft. /Acre)
Comp. Plan
Census Tract
Depth
Frontage
Left Setback
Right Setback
Rear Setback
R/W Width
Additional. Information
•
0
te
0
I
z
z
0
J_
5
m
5 are Footage
330 .0
Number of Bedrooms
:Group ` -:
Type
DEPARTMENTAL REVIEW
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 Date
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
Protect 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 Date