1986, 10-03 Permit App: 00013441 Addition 1. /75 5 3 — / ) _3
(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET �C/" 7
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 Iglect Number � �
LAST FIRST MI '-)lit.-/ProjectAddreess(Street Name&Number)/ /► ► G[
/9/03- . der //P7/A.A9 Zip
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Applicant I )1/i. I Address �`
Ci �D t l Y� CO Q G�til t 19/o S� G , 0 p/
State vR �! LSJ ly
Zip Phone /
rePn a CCP s 6Ua - 9 90/7,2 (; )
Business Phone
( )
Contractor/Agent
1 Address
City I State
Zip Phone
Contact ( )
License Number(Required) Business Phone
Architect/Engineer
Address
0' City State
Zip Phone
( )
Contact
Business Phone
Lender Ph(
)
Address
City State Zip
Phone
I
)
ibe Work
a.,, • Res. Comm.
•
•ivision/Plat Name/Short Plat Number
j
•• Parcel Number
Lot Block Plat Number
a anent File Numbers Zoned. Comp.Plan
Census Tract
} ber of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) I Depth
I p Frontage
F mo,-.-v „¢�T ''4
I Left Setback Right Setback , }- I Rear Setback
WIN Width
Square Footage
.sem .,. r•
O
Q
2
ccO
U-
_Z
0
Z
7
m Number of Bedrooms
BunBuif'oing Technician Date
Group Type
f
DEPARTMENTAL REVIEW
Cond.
Approv=�A Approval Hold
Environmental Health Application# T it f#
gi W.1101 College i
Room 200
\....) Ali ,
I
Planning/Zoning I I
❑ N.721 Jefferson
Engineers I I
❑ N.811 Jefferson
Utilities
0 N.811 Jefferson
Plan Review/Fire Prevention I
0 N.811 Jefferson
Other(SEPA/Critical Material/etc.)
0
i i 1
❑ Fast Track/Special Inspection Information
Project Representative 1 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 /__-":fes 1 _ /
�- ` Date /0 ---.37 -Y "