1986, 08-13 Permit App: 00012630 Storage T_
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(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
Project Number
Owner's Name LAST FIRST MI
Ref BE,p-1 s' ANgrA /e
Project Address(Street Name&Number) Zip
N. 6 33 V z.o l',,�,— 4264-7t4Ct . g9.2. /4
Applicant ^ Address
C e
City State Phone
9e?„-yrte, ai4_ [ZiP99
a0.1f4 .. - ( 9is- 6-9'6 /
Business Phon
l 'zea- 37O/
Contractor/Agent �� Address
Se l.r /I// j V/( 1 CCS'
City
/� State � /yy / 7 (`�j
/N'0 '�'� Zip ! /t//b Phone ( 9, ✓/o /
Contact (I License Number(Required) Business Phone
( )
Architect/Engineer r Address i
Cit
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Y L State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
(
Describe Work Res. Comm.
/ X-1.7,- . e chi/, 71iG� 7`e, C.,11.-r 5'I'�rA/9 ,9A,e,4 d"� (ctoqS Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number Lot Block Plat Number
/S5*-3 '-iioog Cl /
Pertinent File Numbers Zonesr Comp Plan Census Tract
Number of Dwelling Units Number of Buildings / Lot Size(Sq.Ft./Acre) Depth Frontage
Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
�� F-
W -i '7;7'. - ^(__-ar <--.F 0
/ p
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c m' Number of Bedrooms
•i‘:1';';'-'1'.(17;• ?.',":-;-' r ',
Wing Techn Date
Group [ Type
DEPARTMENTAL REVIEW
Cond.
Approved Hold
Approval
Environmental Health -Application M
�
fO �/. --e5X.
PP
W.1101 College
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Room 200 iA • / ,...r. /_ _ _ _
,fir G✓ �'
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Planning/Zoning
0 N.721 Jefferson
Engineers
0 N.811 Jefferson
II
Utilities
0 N.811 Jefferson ..
Plan Review/Fire Prevention u,,,,,
❑ N.811 Jefferson � 6( -
R-f3-
Other(SEPA/Critical Material/etc.)
0
❑ Fast Track/Special Inspection Information
Project Representative Phone
Address
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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.
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Signature. Date
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10
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Show on Site Plan: Additional Information:
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Lot Dimensions Landscaping
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