1984, 10-18 Permit App: 00002909 Repair Fire Damage BUILDING PERMIT APPLICATION WORKSHEET `
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name / (I {first) (m) I Department Use Only
ij r V `�/(�// Res. Comm
2 Project Address(not aillinngg Ad ess)ess)or R Name Space Zip
3 City/Community State Subdivision/Plat Name
U1GK IVO
4 Assessor Parcel No. LotBlock
(l S I.J 30 I 1 * * * DEPARTMENT USE:ONLY * * *
5 Sic Code i• Zone Act.# Zone Project No.
6 Dwell N No.of Buildings Sq.Ft./Acre Depth Frontage
7 Set Back-Front I(L)S-1 (R)S-2 I Rear Census Tract Module No. Initials
* 16 Architect Firm Name Street Address *
Zip City State 'Phone
( )
Contact Person Phone If different than above
( )
Contract Irm Name
� Street A s �
, (� ' Zi_,e `/ /� � /7U ?/
-='-'7 a,2_,A7Z
Zip City / i- .te Phone
7Y' Z e 7 � % ( ) g, ` ‘,._./7u
Contact Person License No. Phone If different than above
8 Owner/Agen�rent t •n 1 above) I 0(0
/'?.2
Business Address
i 0
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(YIN) SEPA Exempt(Y/N) Date
15 Type Work X Bldg ❑ MH E New ;7 Replace 17 Other
Fire 0 Demo ❑ Add/Alter 0 Move
14 Describe Work Fla
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information