1986, 09-04 Permit App: 00012958 MH (THIS IS NOTA 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 Pro]ectNumber
Owner's Name LAST FIRST MI
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/ Project Address(Street Nam &Number) Zip
/ 1 1 f ( U�v.)/
A licant Address �j
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City State Zip Phone
7�l/' ( )f. G s J a
Business Phone
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer _ Address
City State I Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
Describe Work Res. Comm.
•ivision/Plat Name/Short Plat Number
•r Parcel Number Lot Block Plat Number
i - . _ die ( pcf2-/ci. ) I I
inent File Numbers Zone
Comp.Plan Census Tract
bar of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
tSetback Left Setback Right Setback Rear Setback R/W Width
.•itlonal Information Square Footage
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O
"
cr
0
k. Z
C5} z
Ea
5
m Number of Bedrooms
Building Technician Date
� Group Type
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