1987, 03-25 Permit App: 87000733 Remodel - (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) 3
SHADED AREAS ARE FOR DEPARTMENTAL USE
I Project Number
Owner's Name • LAST FIRST
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Project A ress( treet Name&Number) G-,7 /
Y Zip
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Applicant,
Address
oa�J9sJ_ Gy v e,
City State Zip Phone
Business Ptiione
Contractor/Agent Address
City fl I State I Zip Phone
( )
Contact I License Number(Required) Business Phone
( )
Architect/Engineer Address
City State
Zip Phone
( )
Contact Business Phone
( )
Lender
Address
City I State Zip j Phone
Describe Work
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SubdiviSion/Fiat Mame/Short Plot Number ,.... a r.
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Assessor Parcel Number'
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Pertinent File Numbers
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Number of[)wailing Chita - � �{� ;�t,
lot /Acre
front Setl W
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Additions!Intor�ation
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13edroorne
Building Technician !r j� f
DEPARTMENTAL REVIEW
4pproved Cond.
/� Approval Hold
Environmental Health Application# _L,2t1 D✓
W. 1101 College
Room 200
117
Planning/Zoning I I
❑ N.721 Jefferson
Engineers I r I
0 N.811 Jefferson
Utilities
0 N.811 Jefferson
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Plan811 J 1 Jeffe/Fire Prevention
efferson
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Other(SEPA/Critical Material/etc.)
❑ Fast Track/Special Inspection Information
Project Representative
I 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.
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