1987, 01-13 Permit App: 87000069 Addition (THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
• COMPLETE !N INK
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE �CaC��
Project Number
/ Owner's Name LAST 2 �T,i L_r'.# Mi
Project Address(St eet Name&Number) / 5�e'�^' �\ �P Zip
? a / J"- cum g920 Co.
Applicant Address
City State Zip Phone
( I
Business Phone
( )
jContractor/Agent Address
/,re. / /-f, i"( a(--h;-e r- €t3/ r ,cdc,. 4 , I' o _
City State Zip Phone
.,, 64.4u (79 al.0 474 (r67 ) 471-j--S". -&-s3'1-
Contact License Number(Required) Business Phone
Myrteh Mitt aD- Car ( )
Architect/Engineer O//ie/el Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
(
g ibs o ,_ —7-11't? . 1-DEUCERes. Comm.
ASDi-rirOiJ(/2jC(2) .
Subdivision/Plat Name/Stlorrt Plat Number -
vtety �4eees
Assessor Parcel Number Lot Block Plat Number
25tf4— /5 i 5 /5 /5
Pertinent File Numbers. Zone Comp.Plan Census Tract
a": �U Q
- .. s ling Units A,- . Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
, � _- 1x ,; _.. l 15b g5
..
F�nt Setback - Left Setback Right Setback Rear Setback R/W Width
s
'fit-' -3•.'----'::::.7-
m,4 . r' ic)rt Square TY
sus-' f
sew
#*
0
is
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2
1t,--A- 0
' ' a *`
Y_. ,
. ca Number of Bedrooms
tiding Technician Date Group Type
* te /3 S7 L -3
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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.)
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.
Signatur ����G� Date /—/f— R 7