1986, 03-11 Permit App: 00009994 Siding eau C(.-I
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BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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(Please return this original and your building plan to the Department of Building and Safety)
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1 Owner's Name (fast) (first) (m) r Department Use Only
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2 Project Address(not Mailing Address)or Road Name Space Zip
E . /0 /0/ Vr, Flet" (,_.:)Ct-ct 49n,37
3 City/Community State Subdivision/Plat Name
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4 Assessor Parcel No.
t (��/)a/(� / Lot Block * * * DEPARTMENT USE ONLY * * *
5 Sic Code Zone Act.# Zone Project No. 6igq,/
6 Dwell 0 No.of Buildings Sq.Ft./Acre Depth [J� Frontage
7 Set Back-Front (L)S-1 (R)S-2 l Rear Census Tract Module No. Initials
* 16 Architect Firm Name I Street Address
Zip City State Phone
( )
Contact Person Phone If different than above
( )
Contractor Firm Name Street Address
/4( i1cc- j Gro-I/Le1's Cf/Ks, T47.,C. >L) , 31 06 Ary on//c R-oac_
Zip City I State Phone
Contact Person License No. Phone If different than above
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8 Owner/Agent(if different than 41 above) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y/N) I SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg ❑ MH ❑ New ❑ Replace EXQther
❑ Fire ❑ Demo ❑ Add/Alter El Move �G<-/v
14 Describe Work
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10 Applicant Name Street Address
11 Zip City State • Phone
( )
* *
Lender Street Address
Zip City State Phone
( )
'
Contact Person Phone if different than above
( )
Additional Information
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