1985, 11-19 Permit App: 00008807 MH 23533 - 31°C
(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 BuildingI and Safety)
„,,,,„ ,,, _
DEPARTMENTAL USE
Owner's Name LAST FIRST MI
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Project Address(Street Name&Number) Zip
Applicant Address
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Zip Phone
0QetIARAs
Business Phone
Contractor/Agent Address
City State Zip Phone
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Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
lContact Business Phone
( )
Lender Address
City State Zip Phone ( )
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DEPARTMENTAL REVIEW
Approved Cond. Hold
,%r Approval
Environmental Health Application# 9)S—I34 7 I J N/"e5
R5J W. 1101 College ��// �
Room 200 laa/ri .l t' A'l# G S `T ���s - ...�1�
Planning/Zoning
O N.721 Jefferson
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Engineers �1 .009
¢J N.811 Jefferson JKADsy ryHA-'7/6
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Utilities
0 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 to compile said application is true and correct.
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