1986, 03-31 Permit App: 00010265 Roof Cover 'T'I""'.S f� 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
Project Number /r/)
1 Owner's Name LAST FIRST MI
ry N 9- CIf13RLO77 E GPE.enfL
Project Address(Street Name&Number) Zip
6 , 6 7o 11 -- 4/ 4.0 ,,., , q 9'a is
Applicant _ (� Ad s
UfbOtk
' City State Zip Phone
Business Phone
( )
Contracto /Agent Address
emio ,s-c,eem' 00NS'7b E • .3&'O 9 4. 6-hitc '
City State Zip Phone
11U � 9 93 (S c ) 3 3s--s-? O
Contact License Number(Required) Business Phone
j-r t,-s G k__I - ( ) 1,
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
Describe Work. f„� / e 11 Res. x� Comm.
1 bdivision/Plat Name/Short Plat Number
1P%R E 14EY0NTS
Assessor Parcel Number Lot Block Plat Number
VC') _ 27
Pertinent File Numbers Zone
Comp.Plan Census Tract
fl`` ''/4-
•
inter of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) I Depth Frontage
'a t Setback - Left'Setback Right Setback Rear Setback R/W Width
.itlonai Information Square Footage
0 1.
z
_ • O
Q
2
O
U
Z
z
a
m Number of Bedrooms
Date Group _ TYPe
,,-9 / .r-
4-_3/—F4, i4,. ' \J'A 1
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
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
Other(SEPA/Critical Material/etc.)
0
❑ Fast Track/Special Inspection Information
Protect 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 ���? - - ' ' 4w'- Date -Y—,c/-