1985, 08-28 Permit App: 00007216 MH (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 I
Project Number �//,s-.� %
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Owner's Name LAST FIRST MI
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Project
=Project Address(Street Name&Number) Zip
AC/// f 1 2414/ Ge. -2',/ 717A/6
Applicant Address
City State Zip Phone
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Business Phone
( )
Contractor/Agent Address
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City State Zip Phone
Contact License Number(Required) Business Phone
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Architect/Engineer Address
City State Zip Phone
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Contact Business Phone
( )
Lender Address
City State Zip Phone
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Subdivision/Plat.Name/Short Plat Number"
Assessor Parcel Number Lot Block Plat Number
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Pertinent File Numbers Zone , .1Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage .
Front Setback Left Setback r Right Setback Rear Setback
Additional Information Square Footage _ .,
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Building Technician Date rGroup.` Type
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DEPARTMENTAL REVIEW
Cond.
�/ Approved Approval Hold
Environmental Health Permit Number o s-0917 fi ra I'
g W. 1101 College t. 1
Room 200 `' s ,,..'
1:;;"1411,-
Planning/Zoning1?:- /
N.721 Jefferson
Permit Number --] E
Engineers \�!
3 N.811 Jefferson — G NAG G
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 is true,correct,legal,and binding.
Owner's Signature —_ Date
r-- • _ .0444441411MMIN11111.
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SCALE: I IN. -:-'1?";;FT APPROVED BY !DRAWN BY
DATE
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PAC;?17-EL NUMBER. i45.14 - I?' \9
I*DRAINING NUMBER
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