1985, 08-19 Permit App: 00007169 Residence E
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BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
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I (Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number -//y EL
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Owner's hit LAST FIRST MI
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Project Address(Street Name&Nuum er) [_[ Zip
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Applicant
, Address
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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
( )
Contact License Number(Required) Business Phone
14TH4 L do/of 0(l ( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
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v y x .,/ Res. i Comm.
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Parcel Number Lot Block Plat Number
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mart File Numbers Zone Comp.Plan Census Tract
y mberof Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
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* ont Setback Left Setback Right Setback Rear Setback
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•_ditlonai information Square Footage
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'Wing Technician Datey x Group Type
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DEPARTMENTAL REVIEW
Cond.
/, Approved Approval Hold
Environmental Health Permit Number g5--O Q (�`/) p.21-d'�
Ro m 200 W. 1101 College S.{0 % �/5 . 'y 0atiff,
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Planning/Zoning
❑ N.721 Jefferson
Permit Number g,,.,� 4X °; ferson19/4-
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Utilities I
0 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 is true,correct,legal,a. d binding.
Owner's Signature Gt ,� i /-A-/ .-'- �{---\•— Date
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1 - CONTRACTOR:
HIMALAYA HOMES, INC.
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1 - ( 1108 N. TSCHIRLEY
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