1986, 05-12 Permit App: 00010972 Addition (THIS IS NOT A 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 FIRST MI
/0Hi/5roA/ _ flX.Al.VE A •
I, Project Address(Street Name&Number) zip
'I %�hyK 44 r1 '�/
Applicant Address
0../.."..1..." //S!) 1� y.w-x', 44.,A4,,,,,
City State Zip Phone f/
� ,� Gz/0„24. 9f7v ( I ya- y-koro
Business Phone
( )
Contractor/Agent Address
( w .4
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engin r Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
jI (
Descrl . Res. Comm.
•ivision/Plattllama;/ShortPlat Ny9ber
...__..r Parcel Number Lot Block Plat Number
inent File Numbers Zone Comp.Plan Census Tract
.,s ber of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
tSetback Left Setback Right I 9 Rear Setback + R/ W Width
x x ),'`z I F(^W l.. J ext , 6�
� � .. Square Footage
ra x�
Z
O
Q
2
it
O
u.Z
Z
m Number of Bedrooms
to Group Type
DEPARTMENTAL REVIEW
Cond.
Iy /� Approved Approval Hold
�Y Environmental Health Application# 1 / 2' 7
r W.1101 College 0"/Ptir Room 200
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.)
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 to compile said application is true and correct.
Signature Date
,
,F
a or 1
' I 11ST.
Loii // Ij
,
/ — --- — — — — —3....
.
/r , 1 � r ' mow.
!!-GI /L I 'ice, ./AEw AAPI,*ioH
' 8 i-7/--------->1 ,
I I .p f ti:
a8- y ,,
i ao%" ir
3/ire" 'rl % `
� ;4
1 i
t
H
5 1F = _
r = -
I ' . F
I
!1 i #...--,,.,
,'' I
N,Ew ARrvF_
L()KG x r
IP t r II
30.0
t •I
x .
q1 -
13/a?"a / D
.
,,
- t
I
g/ lSs-y3'/ 767 E /a3.t b: v.4•c� 1[t..4r
OLPA/ER, eh..4 riv F .1-•NN'sra r 9 ay-L oft
,4
a..b..i,