1985, 09-12 Permit App: 00007420 MH .t
1
(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
I Project Number
Owner's Name �LLA,ST ,[_ �FIRRSSTq MI 1.-.7-�
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Project Address(Streetme&Number Q Zip
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Applicant Address
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City State Zip Phone
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Business Phone
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Contr.- .r/Agent „.. ."--3,9.-7/7-4...., JD4- 1 b C`_ Address T /
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City State Zip Phone
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Contact- License Number(Required) Business Phone
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Architect/Engineer Address
City State Zip Phone
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Contact Business Phone
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Lender ^ Address
City -. gr-Ak.
tate Zip Phone
Descr be Work Res Comma
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Subdivision/Plat arm/Short Plat Nu ber
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Assessor Parcel Number Lot Block Number
,e, 5r I1 '1 .1 i
Pertinent File Numbers Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
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Front Setback Left Setback Right Setback — Rear Setback
Additional Information Square Footage
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Building Technician Date Group Type
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DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Permit Number
❑ W. 1101 College
Room 200
Planning/Zoning
❑ N. 721 Jefferson
Engineers Permit Number
❑ N.811 Jefferson
Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
ill
❑ 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 is true,correct,legal,and binding.
Owner's Signature i1 , _ Date —72 Y',5
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