1986, 01-31 Permit App: 00009545 Misc. (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 ` x
Owner's Name ,LAST - (9k FIR7.$, E MI
Project Address(Strget Nae mbQr� s e he 0, ,, /) ^/ L) Zip
5 // /f`/ 9 9 6
Applicant/ *' cf
''tt Address
1)d(JK t� V t 0 KO e F7/2.s 7".
City A0A-4/0 State6c)71 Zip O Phone 6 `t
Business Phone
( ) I
Contractor/Agent ' Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City I State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
a # tea%am9
b
x2
' 4
asp? £ d .`d
t*g �.a Front
� „e p '< fa
y so
"p 5 &&: J '"& • i`F' % d a €s as
_ 4 2:,.,, x e " as
nes a a r r
,. ce
8 ."":"4,41.61:500VaSaWreitalF,.+ . gt . 4g .„rte'
DEPARTMENTAL REVIEW
Approved pp
Apprrovov al Hold
Environmental Health Application#
❑ W. 1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
O N.811 Jefferson
Utilities
0 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 co ile s ' ap lic ion is true and correct. ,
.7
/ 3 0736
Signature Date