1986, 03-20 Permit App: 00010263 Duplex (THIS IS NOTA PERMIT) ✓71 Z
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
jeee/
Project Address(Street Name&Number) Zip
/U /I 0- 3 &d/ S i?4' X2 /2
Applicant Address
City State Zip Phone
( )
Business Phone
( )
Contracto (Age t Address
, cL 4 C'-v-Nn� L iC, Or' "7/26.2
City State Zip Phone
(N,4 . 99zix _ ( sa9 ) 9z7- o27Z
ContWI� License Number(Required) Business Phone
5/2uct. /l4-7Pir ,eci,i1C/QC2 175g' 5- ) 7Z7- Z/Z/
Archite,(EngineerAddress
0,6*-r-nik.i6-- --4' ')E-SiGAI AI g 60 S'-- / 14. 67./
City State ZipPhone
GC A, 's Of/4 . /Q QI arer_ _ (509 ) 1/‘2-62,0cj
Contact Business Phone
.-TRIG 5*t,'� ( )
Lender Address
i11/IT Vti, 6o/ /11,4/ A/
Cit State Zi Phone
Y -^�- �' ' p990c)/ ( meq
Describe WorkRes. Comm.
Po
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number Lot Block Plat Number
Pertinent File Numbers Zone �'4� Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Fronts e
35-
Front Setback ,, t Lem tback j Right Setbackr ( Rear Set j R/W Width
4
Additional information Square Footage
MF-- YOS $2 ')Otto
z $ -
0 110X2 = gzo
a CMtoO'f-Z31XZ = 46,2
2
2 Q5CK_ 1IOoyl- = 206
z
n
z
o
D
I:0 Number of Bedrooms
Building Technician Date Group Type
r
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A
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DEPARTMENTAL REVIEW `
Approved Cond. Hold
/j ` Approval
Environmental Health Application# f •
-v 6 `/
14 W.1101 College
Room 200
Afie,..;‘, /.� ,
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N.721
Planning/Zoning 0j - n - 0 J g-1
(� N.721 Jefferson �(� .GK.�C 4
Z / er e"
_6?- f.--&-Si I te,a" -.e 2/ .a€Iv
Engineers 3
2g zi N.811 Jefferson c,m D'f3
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson '3 i2► ig‘.
o 4c \,,,_.,. CI
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 agent • •I pile said appli ion I •=and correct.
illb
Signatur- / /711:11'11W--
Date
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