1986, 07-15 Permit App: 00012096 Remodel(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRIM 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)
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Owner's Name LASTFIRST MI
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Project Address (Street Name & Number)Zip
Applicant
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Address
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City /
State
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Zip
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Phone
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Business Phone
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Contractor/Agent
ractor/Agent
Address
City'
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
T State
I Zip
Phone
( )
Describe Work f
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Res. /
Comm.
Subdivision/Plat Nam ort Plat Number
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Assessor Parcel Number
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Lot
Lot /,
[s
Block
Gig
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
[W c
Depth
Frontage
Front Setback
Left Setback
Right Setback
Rear Setback
R/W Width
Additional Information
BUILDING INFORMATION
Square Footage
Number of Bedrooms
Building Technician
(tib
Date
i- i' -P4
Group
r-
Type
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health
W. 1101 College
Room 200
Application #
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.)
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� JA Date