1986, 09-09 Permit App: 00013079 Addition ,
(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
..� v, 1 ria j t Number Al^y/S
fe LAST MI [ V !�'.,
oject Ad ess(Street ame&Number) P9Zip
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Applicant V dress
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1 City State Zip Phone
**dr ) 9.1v_Gs•I,slanging
Business Phone
memo
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
Lender Address
( )
ess
City State Zip Phone —
1 "77 .. Res. Comm.
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„:„.... Parcel Number Lot Block Plat Number
14 '31 - 1$ai is
Inenf File Numbers Zone Comp.Plan Census Tract
A-IFS
ber of Dwellint Units Number of Ridings Lot Size(Sq.Ft./Acre) Depth Frontage
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t Setrrw Left Setback Right Setb ci Rear Setback R/W Width
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•itionai Information
Square Footage
. 200
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2
0
5
m Number of Bedrooms
.'%•Techn Date
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DEPARTMENTAL REVIEW
Approved pp
Apprrovov al Hold
AEnvironmental Health Application# �
W.1101 College ,/-
Room , ! s
200 S% '(k. --7
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(-1Lo "C.-time(
Planning/Zoning
❑ N.721 Jefferson
Engineers
0 N.811 Jefferson
Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson mi"
4N1,4
Other(SEPA/Critical Material/etc.)
0
o 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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