1985, 10-30 Permit App: 00008613 MH (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
,----s.Owner's Name L ST FIRST MI
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Project Address(Street Name&Number) w�L.L.14Phern-e5Zip
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ApplicantAddress
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City State Phone
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Business Phone
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Contractor/Agent (c)fjlt,i..I(V4 Fr 6 Cf-V Trc'/✓ 66p_ot ress
City State J Zip Phone
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Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
Desscribework -. �' 'a ,b flag -. Comm.
-�-� : 660
Subdivision/Plat Name/Short Pfatt
C
Assessor Parcel Nummbber Lot �j�y Block Plst,Number'
Pertinent File Numbers coin..Pian Census Tract
Number of Dwelling Units Nurrrberof Buildi It Lot Ft.IAcre) t Frontage
1 i :.' .S r
Front Setback Left k6 t Right Setback ° ';'.!....,1144C''.'„''' fliW Width
Additional Information , ae
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m f of.Bedrooms
iding Technician bate Gro Ty
DEPARTMENTAL REVIEW
Cond.
fL Approved Approval Hold
jEnvironmental Health Application# r�/3T(W. 1101 College
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Room 200 T(77
Aci'l.ii.. f-ii,M-i/IX-11/
Planning/Zoning
❑ N.721 Jefferson
Engineers N. t .
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N.811 o��n � �� — �-
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Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
E
❑ 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 ageat-to-cer pile said app ' ation is true and correct.
_� /
Signature `� Date �–