1986, 08-11 Permit App: 00012563 Tank -r 444000 (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 and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number
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/ Owner's Name LAST FIRST MI
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t Project Address(Street Name&Number) Zip
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Applicant Address
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City -1State Zip Phone
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Business Phone
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i. Contractor/Agent Address
CAL As
' City State Zip Phone
“350, / 77 r'N/ c._)A , 1 i'an; ( )
Contact License Number(Required) Business Phone
,J12- Py ' /1 /L&T/ CAC-, G/ 2(3NM ( )
' Architect/Engineer 2 Z-3 D i Address
City State IZip Phone
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Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
Describe Work Res. Comm.
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Subdivision/PlatName/Short Plat Number
Assessor Parcel Number Lot Block Plat Number
Pertinent;File Numbers Zone Comp.Plan Census Tract__
Numberof"Dweling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage -
, a.
Front Setba k Left SetbackRight Setback Rear Setback
Additional Information i Square Footage
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•BoitdingTechnician. Date Group
- • •-. Type - -
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Permit Number
❑ W. 1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Permit Number
Engineers
❑ N.811 Jefferson
11101111.1
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 is true,correct,legal,and binding.
Owner's Signature Date
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