1986, 10-02 Permit App: 00013398 MH (THIS IS NOT A PEI-IMIT)
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 USEI �_ ,,,r,
Project _
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Owner's Name LAST FIRST MI
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Project Address(Street Name&Number) Zip
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Applicant Address
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Business Phone
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Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
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Architect/Engineer Address
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City State Zip Phone
( )
Contact Business Phone
( )
Lender
Address
City State I Zip Phone
( )
Res. Comm.
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••tviston/Plat Name/Short Plat Number
44 c Mo t E ...PAR_K., C,,mc ? t Ew
•.r Parcel Number Lot Block Plat Number
Pertinent File Numbers Zonk II. Comp.Plan Census Tract
not
Number of Owling Units Numberf Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
Front Setback Left Setback Right Setback Rear Setback R/W Width
`. Square Footage
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m Number of Bedrooms
i ,T Uate Group I Type
DEPARTMENTAL REVIEW
Approved Cond.
Approvalfl)Z Hold
Environmental Health Application ME.(_01221— �7j ��
W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
O N.811 Jefferson
Plan Review/Fire Prevention
o 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 to compile said application is true and correct.
Signature 1f� �A_ Date /( -�� O
1