1985, 10-23 Permit App: 00008237 Special Inspect -
(THIS IS' IOT 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
Owner's Name LAST0 FIRST MI
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Project A rens(Street Name&Number) Zip C
Address
Applicant y
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City State Zip Phone r
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Business Phone _
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Contractor/Agent Address
City State Zip Phone
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Contact License Number(Required) Business Phone
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Architect/Engineer Address
City State Zip Phone
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Contact Business Phone
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Lender Address
City State I Zip Phone
Describe is e :- w (, )
Subdivision!Mat Name! t 'N
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Assoc Paroel;iVucngsa
15 �<
F'srtirtent FNe t3umtaers -, . ;A � � i;
.", Comp.Plan ' Census Tract
Number of Dwelling Units
of ° ( Ft!Acre)`-: Dep Frontad
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Front Setback , X Se` •
9 � k ��Y width
Atit11#iamaF Informativn
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Group Type
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