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1986, 09-29 Permit App: 00013339 MH
(TH;�S 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 LojectNumber ��2 � Owners Name LAST FIRST MI �✓�J tea-i Geb A A. Project Address(Street Name&Number) Zip S r 18 �z �/�1_4-C`7c�>� ( �9ci Applicant Address -� Jl ��©t�c�� A . rl� /9 Name L i4c City State Zip Phone Spm � W4 9°�vv7 (s69 , &/ _2 D5 / Business Phone (So9 ) 92'7--�5&co .�uf 39Y Contractor/Agent Address City State Lip Phone ( ) Contact License Number(Required) Business Phone ( ) Architect/Engineer Address City State Zip Phone ( ) Contact Business Phone ( ) Lender Address City State Zip Phone f z R �E Comm. imp. �$t Npm r t� A-1O L , +bet Lot Block Plat Number n Zone_ �w. T act N Comp.Pin Ceasesr - #lits Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage Y , . / £ Lett Setback; Right Setback "Rtarsetbat�t„ R/WWidth �' :t" .� � __:_.:,;:„,,11r,,, �� Square Footage .-. .-,aa '.,a i t55� �.d'�xri ..- Z 0 '^ x • m Nturtber of Bedrooms w T nlr�fai Date Group Type DEPARTMENTAL REVIEW Cond. Approved Approval Hold � '{} p Environmental Health Application I A 1-0 "�w; W.1101 College Room 200 Ci°4ant-3-4-j Planning/Zoning D N.721 Jefferson Engineers D 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 to compile said applicatio is true and correct. Signature `jar) J�-CLZ Date 9/.21e60