1985, 11-04 Permit App: 00008488 MH r
(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
SHADED and yourAREAS building
AREFOR plans toDEPARTMENTAL the DepartmentUSE of Building and Safety)
II € ei�t Nattet
Owner' Name LAST FIRST MI
Zip
Project Address(Street Name&Number)
N -/ 1...,./1..),-k. /?61, 9?
Applicant Address
City State Zip Phone
( )
Business Phone
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
,, s Gomm.
° �Dssci(be x Subdivis n/P t t t �
'-'!i-''''",:,'A,J."---4114-"-';..'-.. .,-21,414.46::-:','561: ,' ° ' ' '';','
Assessor Parcel Number Lsst r
#cdc Ntimr
Perttnent Fite Numbers. Zone �;otktP:::iirf*it:1::::-/-.,!';''',::::::::', -',.-: :21 ':'''°' '-*''- ' 2' R1iri Ti
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t'tNu1a 1 ke ,�*�.i {7sq 1�t=J.,rAcEre} .,„..,,_.,,,,:---,-'-.:.-,10
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mter of Gveltirfg ht _ fAN� t, ; RRightSetaa ` - ;Front Setback
Additions!Information
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'BuildingTechnkian I - Type
�" '� YN
Adir
DEPARTMENTAL REVIEW
/
Approved CpApproval Hold
Environmental Health Application# r ) 44 r
W. 1101 College /4 //
Room 200 1
Planning/Zoning
❑ N.721 Jefferson -
Engineers
❑ N.811 Jefferson
Utilities
El 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 4j77 « �+-��� Date 71— 11— �_
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