1985, 12-30 Permit App: 00009260 Fireplace (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
Prn)eeQ Number (4,2....G„0
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Owner's Name � LAST �C�-'��i�t�/7�, FIRST MI `�
///.ter G/ -e—e
Project Address(Str t N &Nu ber) Zip
Applicant Address
City State Zip Phone
( )
Business Phone
( )
Contractor/Agent Address
City State Zip Phone
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Contact License Number(Required) Business Phone
/_Y0'T S', ?71 Ng
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
y ,µ .ReB. Comm..
eta Ply
Y5 8A
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[ » Lot. ; Stock Plat Number
o ' _ 071'
inert Ftte .-, Zone Comp.Plan Census Tract
of Dwelling Unite Number of•Buildings " Lot Size(Sq.-Ft./Acre) Dapth Fronta e t
3x
t Setback ' Left Setuilok Right Setback:. Rear Setback R/WWidth
y t Square Footage
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Informatia , . �}
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2
x •
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03 Number of Bedrooms
Cling Technician .. Date ..,
Group TYt�
DEPARTMENTAL REVIEW
Cond.
Approved Approval 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 Date