1986, 08-14 Permit App: 00012634 Garage (THIS IS NOT A 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
Owner's Name 7- LAST n FIRST MI
oject Ad ress(Street Name&Number) Zip
S `O,), it)/).;-Amk % it S 4
Applicant Address
I.4Ays .T I-1,Ess
City State Zip Phone
S tn�,k-AN.' A _ c Id l C—
IL) (�p ) C3c/- 7rt�F�
Business Phone
Contractor/Agent Address
Srcr=
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
L A
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Work , a wr r r c - " � `
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Assessor Parcel Number -'^ `. `x`
PertInent File Numbers Zona" ' compo P1ar a
Number of Dwelling Units Nt�tnh9� r Ea€ Ft lAcre tage
$iF9s A i Fron
Fron tback i eft S bad Right Setb t Set ` /W W1dtW —
Additional information S9uare o ge
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Number of Bedrooms
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Building Technician Date r p y Type
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DEPARTMENTAL REVIEW
Approved pp
Apprrovov al Hold
Environmental Health Application I
IR W.1101 Rom 200 College (\AU C-01'vGFt C)(�
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.)
El
❑ 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
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