1986, 04-22 Permit App: 00010959 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 .I 10�5�1
Project Number
Owner's Name _A/,,, LAST FIRST MI
� /fie. --" 790027
Project Address(Street Name&Number) Zip
S. 7 5' 'rider/n 0/
Applicant Addr
City State Zip Phone
C IS CAZIna IOS Cul \ f d 9,7 ( 50? 9 .C)C/
Business Phone
( 1
Contractor/Agent Address
Cl/d?6
City State Zip Phone
( 1
Contact License Number(Required) Business Phone
\'‹MA.LAC-4C2.2 ,,(r ( )
Architect/Engineer Address
City State I Zip Phone
( )
Contact Business Phone
Lender Address
City State Zip Phone
( )
Describe Work \ Res. Comm.
1 t-- in ; t r ICt `-}{ v R .,c ✓
Sub ivision/Plat Name/Short Plat Num r h
td X74. � ;i 7 _ C9�_A) .z� S /�,
Assessor Parcel Number LotBlock J Plat Number
.1(54/., /3
S)S' y f
Pertinent File Numbers Zone }� Comp.Plan Census Tract
A/1
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
P////// ZOO /c /ye/ , /' / -(7 /CO
Front Setback , Left Setback t Right Setback Rear Setbacis R/W Width
.' � 54> gs 40
Additional Information Square Footage
Z 8104- --CI G
0
~
a 80 = DECK
2
0
;
� u.Z
, : a
-J
5
m Number of Bedrooms
is T Date Group T
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DEPARTMENTAL REVIEW
Approved Coed. Hold
Approval
04if I r it
Environmental Health Application# A' (r 4* •
W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson ,/ge
—
Engineers /� :V23
N.811 Jefferson K / 7 r
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
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 application is true and correct.
Signature _ c / I'LL" Date =?`1;:,2/18
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