1986, 09-18 Permit App: 00013256 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 ProjectN_umber I'�� '
/_
Owner's Name pyo ,y LAST y�FIRST MI,Z
1 4
Project Address(Street Name&Number) Zip
2-AST fV9-LLz Y Cxki-y / S2// 77-4' )/
Applicant Address
�.�X / V 'O i ,1 - / .- 32/ ` / P
City State
ZO�pK//J 9 Zip r/�// Phone Q// c//�/} 2 7
Business Phone
(-SS' ) . '7—,o yc
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( I
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
(
I
Lender
Address
City State Zip Phone
( )
x1 : : Res. - Comm.
� r
+ s,„ Mat Name/Short Plat Number ,' } •
ar f cfi^8" " aR�--4't"-'-s -1 ! • _ i, ]�t I ''�� t f • f
?t esS Parce@Number Lot Block
r�` .� jj++,,/' - plat Number
�t Numbers. Zone
„�,� � Comp.Plan Census Tract
Numberof Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
' t
Froetback
nt S .-•, Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
O
G
i
0
LL
z
Z_
0
J_
5
m Number of Bedrooms
Building Technician Date, Group Type
DEPARTMENTAL REVIEW
Cond.
Approved) Approval Hold
'
Environmental Health Application#
W.1101 College
A
Room 200 / 'j ��'/'!
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.)
o 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 Date