1985, 11-01 Permit App: 00008462 Addition (THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please retur,-i this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USErwi
Owner's Name h/c LAST FIRST I
ate st- tiro A/ ,7
Project Address(Street Name&Number) Zip
9 4 F. v•01/ y w1-0 r VE R vi i.Q Gv'a s Atea Y"
Applicant // Address
4vcl,v�
Cit Ze State Zip Phone
VI k/4 rL 111 A 9y' ( ) q‘ - . •.r/7
Business Phone
( )
Contractor/Agent Address
�J R �/(A,.L L. S ?t 1`1.-
City (1 State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
Describe Work , n R C.cuttm
Subdivision/Rat Name!Shoft Pim
Assessor Parcel Number.
e ,.. . Int.",, :, •, Block Plat"Mbar
rr
(3 "°ti
Pertinent Fite Numbers Zone Gamic.Plan Cel Tract
Number of Dwelling Units Numberof Lot S ($q Ft:/Acre) Depth ; Frontage':
Front back Left t c` RightSetl ck" iT RearSyet k R!W Width
Additional information SquareFootage
r , d
a
att Number of.Bedrooms
Building Technician Date Group Type
DEPARTMENTAL REVIEW
Approved Approval
Cond. Hold
...Approval
Environmental Health Application# (/`/ i►
IJ W. 1101 College ��
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.)
❑ 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 compile said application is true and correct.
JDate 1/-
1 '
Signature `...„4.%�.
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PRNITIT 7`f l_11)
17 P L A 11) . .
SCALE