1986, 07-10 Permit App: 00012040 Garage(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
Owner's Name
LAST
Project Address (Street Name & Number)
/20/?
Applicant [3,e h y /1._- /lam
/44- 1 ! S r Cc9.tJ5
City
SpG A cQ
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FIRST
MI
"7/74-1I-7 te, /Fc)
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Zip
Address
State
Zip
'9,a (:
lv c) 2 G 3 4c .n -t 5 A'J
Phone
(may' 7
Business Phone
Contractor/Agent
MA- TS
Co
City
ri l A.Ic_-4.--
State
C?i4
Zip
9-2c %
Address
AiP22 ,11-c(/9A-cs /Pe%
Phone
Contact
License Number (Required)
MA-1iii e (:)
Business Phone
(
Architect/Engineer
/Vc.,
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
Describe Work.
Subdi
/PI . Name/Short Plat Number
°IVO21-01Q
AssessorrParcel Number
I 4' —
Pertinent File Numbers
Zone
Comp. Pian
Census Tract
Number of Dwelling Units
Front Setback
Additional Information
Number of Buildings
Left Setback
ext
Lpt Size (Sq. Ft. /Acre)
Right Setback
1 I ( G foAPP, \-1
Rear Setback
Building Technician ( Date
Frontage +.
R Width,
Footage
z
0
a
cc
0
z
z
c
m Number of Bedrooms
Group:
Type
DEPARTMENTAL REVIEW
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
Approved
p
Appprrovov al
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
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 to compile said application is true and correct.
Signature Date