1985, 08-07 Permit App: 00006730 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 plar2s to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number 3n
Owner's Name LAST FIRST MI
Project Address(Street Name&Number) Zip
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Applicant
Address /
City State Zip Phone
( ) 72 2—
/
— %793
Business Phone
( )
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect)Engineer Address
City State I Zip Phone
( )
Contact Business Phone
Lender Address
City State Zip Phone
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DEPARTMENTAL REVIEW
Approved CpHold
'57,5sj � Approval
Environmental Health Permit Number
W. 1101 College / �
Room- QQ re
A/0
Planning/Zoning
❑ N.721 Jefferson _
Permit Number
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Preventior
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
❑ 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 Date
1
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A-e-r—c vel
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35
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DUAKE 3 LORETTA SEYERSON I
19020 E 4TH AVE. tLoT T'L A
GREERACRES.WA 99016
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