1985, 08-22 Permit App: 00007051 Addition •
(THIS IS 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
I Project Number
Owners' Name LA / FIRST /, MI
�,
Project Address(Street Name& )
Numb rZip
�°- b - / 97,,242
Applicant Address
City State Zip Phone
( ) 534 - 2olv
Business Phone
( 1
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State I Zip Phone
I ( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
Deatxlbe WorkRes. / Comm.
tr)gVie WO m k)O) 110 °l \/
Subdhviion/.PIatName/Short Plat Number .
X I LCI)( >l
Assessor Parcel Number Lot Block Plat Number
3 53 Z - 43 o f 1 .
Pertinent File Numbers Zoog f/l Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre):< Depth i Frontage i
I 1 / 7
FrgntSetback . Left Setback Right Setback,. Rear Setback
"; ,-: i V # Square Footage
�fi A a ,r,.: tq +, Iry -�,, ...„,,„.
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Building Technician Date Group Type
J0 rn • �' /Zz/81 2 _ ,: v
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
13, Environmental Health Permit Number gc v/� r /
W. 1101 College �'
Room 200 /Of
Planning/Zoning
❑ N.721 Jefferson _
Engineers Permit Number
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ 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