1986, 05-27 Permit App: 00011299 Addition •
(THIS :IS NOT PERMIT) �b
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 VSE prbjecf NcHribef !!1
Owner's Name LAST FIRSTI!
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Project Address(Street Name&Number) -- ;p
Sf / 72 / U e`-A 6"..e_574 -S' 44.t..� G(2.,. 1`�6
Applican CoAdddress
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Cit State Zip Phone
Business Phone
AddressContractor/Agent / e/ TsJ5 �a�✓ S
Z"dr; 040 /Z2-•
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City State Zip Phone
4:e-e- --15, ,t? rti tOsc '7 ( )
Contact License Number(Required) Business Phone
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Architect l Engir,eer. Address
ill <I,_e _S-A) .eg--Adie S. /72( 0ek-t C • A
City State Zip Phone
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Contact Business Phone
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Lender Address
City I State Zip Phone
Res. Comm.
,, ,,,,, .....-:',4::- ,,...... ,.. ,,,,A 6 G (.>A o -2,..e))abdivision/Plat Name/Short Plat Number
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Assessor Parcel Number Lot Block Plat Number
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Pertinent File Numbers Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
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Front Setback - Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
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m Number of Bedrooms
+ Date Group Type
.57727/86 di _f �/.•,
DEPARTMENTAL REVIEW `
Approved Approval Hold
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Environmental Health Application# A
❑ W.1101 College /
Room 200 SEWS /i
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention
N.811 Jefferson be9
Other(SEPA/Critical Material/etc.)
0
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
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RESIDENCE S 1721 VE
SCALE: I/5 = 2.1 .•APPROVED BY:
DATE: MAY 4„, 19eijo.
ADD1 T V)N1GAME ROC
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