1986, 03-20 Permit App: 00010258 Duplex (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 1
Project Number ,0
Owner's Name ........, s _FIRSTp MI
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Project Address(Street N7ame&Numbber) �` /� poi
IU ENL A) 9(.,: 2 S AT ,/1 Zip
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Applicant Address
City State Zip Phone
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Business Phone
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Contractor/Agent Address
/rcs��]Y[ ec),VSi-EU C776A1 /vc..... t1 rcr r /926,, -
City State Zip Phone
clic, e w A . 99z;y (56,9 ) 92,7-p 27 Z
Contac License Number(Required) Business Phone - O037„ (�no61 k,)
11 vrE 1i1477//S reeS44 11 a bid. 9 ) 72-7-Z/Z i
Architect/Engineer ° +1e G Address
JCA-FnNCs $ E &i Ji 1 R1 5'los- 'Div/s/0A)
City State Zip Phone
SPe)KAVelt, JA . '192 ov (coc" ) %,7- 62,643
Contact Business Phone
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Lender Address` -
W45/4 141ur 1A1G f4f4-r,v)
City State Lip Phone
s� e— 1p;i4 17' 7 ;/ ( 54 6,6,y
Describe Work , Res. Comm.
Subdivision/Plat Name/Short Plat Number
i-:' l=� PF i.2 NO 1.101Q
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 f Frontage I
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Front Setback ,f. Left Setback Right Setback Rear Set I R/W Width
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Additional inforriiation— Square Footage
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m Number of Bedrooms
Building Technician Date Group Type,
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DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application# J" —Q 6.902
W. 1101 College
Room 200
Planning/Zoning /�,/ff
N.721 Jefferson :7
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Engineers �(
V. N.811 Jefferson ��
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson za / t
Other(SEPA/Critical Material/etc.)
0
❑ 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 agen .moils said application is tr - =nd correct.
Signatur- Date
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