1985, 08-19 Permit App: MH(THIS IS NOTA PERMIT) )--ec IL
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 DEPAH I MEN I AL USE
L t Project Number
Owner's Name LAST FIRST MI
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Project Address (Street Na e Nummb(errr)) J/ ,/ %� Zip
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Applicant U ff_
Address
City ,,��tt
Aa 11
State
Zip
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Phone
(p 6 ??6 f
) +
Business Phone
gug
( )
Contractor/Agent
'----C E /C
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( I
Architect /Engineer
Address
City
State
Zip
,.,phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
( )
Describe Work
t _ f
Rea.
Comm.
Subdivision/ Plat Name/Short Plat Number
Assessor Parcel Number
;,;
Lot
Block
Plat Number
Pertinent File Numbers
Zona
Comp; Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Front Setback
Left Setback
Right Setback
Rear Setback,
, —�—�
Additional Information
DEPARTMENT USE
Square Footage
Group
Type
Building Technician t Date
DEPARTMENTAL REVIEW
I certify that 1 have examined this application and state that the information contained in it and submitted
by me or my agent is true, correct, legal, and binding.
Owner's Signature./L.
Date :/ C1,S
Approved
Cond.
Approval Hold
Environmental Health Permit Number /-263 r
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W. 1101 College
A 2QD
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fixeir
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4
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
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Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that 1 have examined this application and state that the information contained in it and submitted
by me or my agent is true, correct, legal, and binding.
Owner's Signature./L.
Date :/ C1,S
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