1986, 08-04 Permit App: 00012541 Addition r
(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
Owneslsame Project Number
/� 2 LAST FIRST
A MI
Project (Street N & umber)
^o� S l�//J / Zip
Applicant
/' „' 7/J41--- --rjA7 / p< KIM S /,�
/ Address
•
1 City
State Zip Phone
9.26 —/276c
Business Phone
Contractor/Agent ( ) '-
l Address
iz
City State
Zip Phone
( )
Contact
License Number(Required) Business Phone
Architect/Engineer ( )
I Address
City
State ,
Zip Phone —
Contact ( )
Business Phone
Lender ( )
Address — —
City I State
Zip I Phone
Describe Work L ( )
I Res. + Comm.
rC
4..,, .E Api1T ion (AO x20 6Ar#- lir
Subdivision/Plat Name/Short Plat N mbar
ick)fVeRSITy PL,gce ted H
Assessor Parcel Number
2054{ ' 27 Lot Block
�7j` ele, Plat Number
Pertinent File Numbers
Zoneks Comp.Plan
Census Tract
Number of Dwelling Units Number of Buildings Lot Size
/(54� Ft./�A`re) I Depth Frontage
Front Setback I Left Setback f �O
Right Setback I Rear Setback
R!W Width
Additional Information
Square Footage
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p
S
m Number of Bedrooms
Group Type
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DEPARTMENTAL REVIEW
Cond. Hold
Approved Approval
Environmental Health Application#
❑ W. 1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson C
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 to compile said application is true and correct.
Signature Date