1986, 07-18 Permit App: 00012155 Addition I r
(THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLYTHOSE 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 55
I Project Number /�/
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Owner's Name LAST FIRST MI
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Project Address(Street Name&Number) Zip
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Applicant Address
City State Zip Phone
( )
Business Phone
( )
Contractor/Agent Address
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City State Zip Phone
ContacttLicense Number(Required) Business Phone
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Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
Describe Work Res. / Comm.
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Subdivision/Plat NameIT1LLV / L,
Plat Number
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Assessor Parcel Number Lot , ; Block Plat Number
f..-7 5 1-/-, _d(,t : /1
Pertinent File Numbers Zone Comp.Plan Census Tract ,:
Number of Dwelling Units Number of Bulidings ; ' iot Size(SQ Ft/Acre) Depth Frontage,
ont Setbacc -.1!4-4;",'"". Ree SetbacR/W Widtf , 'k Lett Setback G$. ,,, ;Right Setbak . '
Additional information n Squa e
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a n m Number of Bedrooms s
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Building Technician Date z ,. fi� {r c. a ' ' Group-," Type
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DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application#
U W. 1101 College Sr~c�l
Room 200 �J g,
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
0
❑ 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 Date Vi 6 AC)
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