1986, 04-18 Permit App: 00010581 Addition (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 (,proJectNtfmber
Owner's Name LAST FIRST MI J
Project Address(Street Name&Number) Zip
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Applicant Address
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City /� State Zip
Phone
5 n a /'t 4 Gr e -- U(/ /y 1-J Z. I l > .,_513 S_—��j cr S
(/ Business Phone
Contractor/Agent Address
City State I Zip Phone
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Contact License Number',Required) Business Phone
( )
Architect/Engineer Address
City State 1 Zip Phone
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Contact Business Phone
Lender Address ( )
City State Zip Phone —
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Fibs Work Res_ Comm.
tv►ston/plat NamelShot Plat Number
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:Assessor Parcel Number Lot Block Plat Number
In CI
Pertinent File Numbers, Zone Comp.Plan Census Tract
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Number of Dwelling Units. Number 0141i!dings Lot Size(Sq.Ft./Acre) Depth S Frontage
1 '3 75
it Setback =; Left Setback Right Setback f Rear Setback R/W Width
S,
:Additional Information Square Footage
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m Number of Bedrooms
Techn tan' DatGroup Type
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application# 7'1/f
tar W.1101 College �
Room 200
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Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
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Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
El 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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