1985, 12-03 Permit App: 00008986 Addition !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 1 PrnjectNumber
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Owner's Name / LAST / IRST MI
Project Address(Street Name&Number) Zip
/3a6- /V G;/ ze .-SreAid, w,1.
Applicant Address
'7.-:, 0e),&, r-7-'.A 41,0 v / V. a -c /4va�
CityQ ibl- ( # State /' Zip 9� Phone
/ Business Phone
Contractor/Agent / , Address
37-7, 7/ - l', c /7 c ,�a� J``' J..—r- 4.l eC_o .�A' ,
City State Zip Phone
a1,2. 79 6. (.� .2___e :Is-7 -7/
Co act Lic n r�ber(Required) Business Phone
Li k /2 OF ( )
Architect/Engineer Address
`i1 e 4_;7'-
City State Zip Phone
( )
Contact Business Phone
( )
Lendery Address
4Cs®/C1
City State I Zip Phone
( )
IibeWr p Res,' Comm.
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vision/Plat Name/Short Pl3t,Number
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ssor Parcel Number Lot Block Plat Number
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Pertinent File Numbers Zone Comp.Plan Census Tract
tA C.-S C i 6
mber of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
Front Setback Left Setback Right Setback Rear Setback R/W Width
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Additional Information Square Footage 0
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*-' m Number of Bedrooms
Building Technician Date Group Type
DEPARTMENTAL REVIEW
Approve. CHold
Approval
1 Environmental Health Application# j,
���JJJ W. 1101 College
Room 200 /1-3-15
Planning/Zoning
O N.721 Jefferson
Engineers
O N.811 Jefferson
Utilities
O N.811 Jefferson
Plan Review/Fire Prevention
N.811 Jefferson
Other(SEPA/Critical Material/etc.)
O 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 ae-nt to compile said application is true and correct.
Signature Date / s
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