1985, 10-14 Permit App: 00008393 Duplex (THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET �a
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 NameLAST FIRST MI
A
2/ it-3,4_2 L
Project Address(Street Name&Number) / Zip
N ‘3,A) g Lt.). A�c,�2 Ct-
Applicant Address
S m E V--2/ /.4.2.&11.42-
City . State Zip Phone
Business Phone
Contractor/Agent Address
City State Zip Phone
Contact License Number(Required) Business Phone
G1'mk1r
Architect/Engineer J Address
A2
City State Zip Phone
Contact Business Phone
Lender Address
City State Zip Phone
Describe Work Res- Comm.
C)U/DL. x
Subdivision/Plat Name/Short Plat Number .
/ L;C.✓ `�1✓'C'E. ! + / '
Assessor Parcel Number Lot Block Plat Number
aIf y I 1 r Z_ !2_
Pertinent File Numbers Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
/ ! COC
Front Setback Left Setback Right Setback Rear Setback R/W Width
30 w
Additional Information Square Footage
/&6,5 -- 1--u1
q75 = ug
a 615 OA-R
2
_
3
m Number of Bedrooms
Building T hnician Date Group Type
F;E` r-3 vttil
r
114
DEPARTMENTAL REVIEW
Approved Hold
Approval
Environmental Health Application# f 6`� TJ /%y
❑ W. 1101 College S f yy�
Room 200
Afir ' ;Ir
Planning/Zoning
O N.721 Jefferson
Engineers �n ` 6 5
❑ N.811 Jefferson .(�
Utilities
0 N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
Cfr-)\
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 to compile said application is true and correct.
Signature Date �l
1
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