1986, 10-10 Permit App: 00013551 Remodel(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 LAST /�l/ fFIRSTIl
Mars4a- fl` � 4 F (/Cv,/ac`rer
Project Address (Street Name &Number)
////P
Applicant
State
MI
�td/rane Wa ff Rob
Zip
Address
Phone
Zip
(gip ) qa6—413
Business Phone
Contractor/Agent
Address
State
Contact
License Number (Required)
Architect /Engineer
City
Contact
Lender
City
Phone
Business Phone
(
Address
State
Phone
Business Phone
(
Address
Phone
Plat Number
Census Tract
Frontage
DEPARTMENTAL REVIEW
I certify that 1 have examined this application and state that the information contained in it and submitted
by me or my agent to compile said application is tru and correct.
Signature
Date 76// V612‘
Approved
CpApprrovov al
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
I
I
Engineers
N. 811 Jefferson
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 1 have examined this application and state that the information contained in it and submitted
by me or my agent to compile said application is tru and correct.
Signature
Date 76// V612‘