1985, 12-06 Permit App: 00009045 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 ay.,„ »
Owner's Name L T FIRST MI
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Project Address(Street Name&Number) . Zip
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Applicant Address
City State Zip Phone
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Business Phone
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Contractor/Agent
Address
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City_ State Zip Phone
.0:eContac License Number(Required) Business Phone
Architect/Engineer Address
City State Zip Phone
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Contact Business Phone
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Lender Address
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City State Zip Phone
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DEPARTMENTAL REVIEW
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Approved Cond. Hold
Ap royal
Environmental Health Application# C
W. 1101 College /�/i//'"
Room 200
Planning/Zoning
❑ N.721 Jefferson
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Engineers f,v W/d Gl• ���,
N.811 Jefferson �1 i7 O
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Utilities
D N.811 Jefferson
Plan Review/Fire Prevention
L N.811 Jefferson VVV
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 -••lication is true and correct.
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