1986, 12-11 Permit App: 00014503 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)
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SHADED AREAS ARE FOR DEPARTMENTAL USE _
Project Number � 2�
Owner's Name LAST FIRST MI �C �
So r reLJ- RtF,E__c_tA -Z-
Project Address(Street Name&Number) Zip
F . 18813 VRLI Ey Way gieFAIAc eE5 996/4
Applicant Address
City State Zip Phone
(seg ) 92L—.3SSg/
Business Phone
(S-, ) 5-3S/— 2z 9Z
Contractor/Agent Address
City State Zip Phone '
( 1
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.
Coc.ceL..E WOE x, 0iBl[ C-( Kea?)
Subdivision/PlatNa Plat Number
'2 )W14EQ0 IS i/073li 111:21 - ADD
Assessor Parcel Number Lot Block Plat Number
# S55 -270 V 7
Pertinent File Numbers Zone Comp.Plan Census Tract
'N'umber of Dwelling Units Number of Buildings Lot Size -
(Sq.Ft.lAcre) Depth Frontage
l 1 I 144 L.A�__
Front Setback ' , Left Setback Right Setback Rear Setback
Additional Information Square Footage .' „
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Building Tech ician Date Group ,J ..
.,. . 12--11—
•
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Permit Number
1/ W. 1101 College / V
Room 200
Planning/Zoning
❑ N.721 Jefferson
Permit Number in' �'
0, Engineers
N.811 Jefferson /a /f A
Utilities l
I: N.811 Jefferson I
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 is true,correct,legal,and ding.
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Owner's Signature r___ `__ Date