1985, 11-21 Permit App: 00008866 Repair Fire Damage (THIS IS NOT A 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
I -80E76
Owner's Name a LAST A FIR T MI
Project Address(Street N.me&Number) f, Zip
d/2/:c /. ��1a V
Applicant Address
( V � �2f 1r.1L- /'D/ /7/5-66
City State Zip Phone
__ A4:-i. /di?, r).;2//1/ ,) 9a7— F
Business Phone
( I
Contractor/Agent 1-2- Address
City State Zip Phone
( )
Contact Li ense Number(Req it ) el/ Business Phone
LA 'IeECC. /fit OO ( )
Architect/Engineer 2 7966
jAddress
City State C Ziip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
Describe Work ....„, _ ;ii':,,'",',.' :-":.--,Iiii!''.;;;}!;!„Yi-7,:.:.''--'i-e-V-;1,-e,:''e'''.:;-i''''' ' ' -°----'-'''-',. .' -. ,---r-- , -''''`iiffig '';'''''''''''''''il-'";-:'''-','-''
ork '
.-Comm.N
Subdivision/Plat Name/Sheri Plat Numb '
Assessor Parcel Number ' 1.174t. -. Bloch Plat Number
675V3- Q01—
Pertinent File Numbers # Zone Comp + Census Tract
Number of Dwelling Units rt Nurnber of Buitdtngs Lot Size( .ft./Acret Depth' Frontage
Front Setback Left Setback 1. ', ,:Right Setback Rear Setback :. RiW-Width-
Additional Information Square Foot
2 V4LLl4rry 1
0
a >
U.
0
Number of.Bedrooms
Building Technician Date Group Type
0-1Y6121 _ t VN
Imilmminmmaraw
Show on Site Plan: Additional Information:
Lot Dimensions Landscaping
Existing Structures Drainage Plan
Proposed Improvements Hydrants
Structure Setbacks Topography
Easements Lighting __.
Septic System(s) Signage
Water Lines Shorelines
Sewer Lines Highwater Mark fi_
Fences,Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Legal Description
75Fr NE 'OFT
U) CF . eoR CaF /`,E '/
OF // Pittiz, 70
rNOri wA A vv 2l'y,-,T 7-14
N �5 FT %l-j E z6V c r 7H
6/5 FT -r tP-oe
Scale:
Date:
Revisions: Attachments:
DEPARTMENTAL REVIEW
Approved pp
Apprrovov al Hold
Environmental Health Application#
❑ W. '1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/CritIcal Material/etc.)
❑ 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 i&L_ (11/1:4- Date //._ a/— /5