1986, 07-23 Permit App: 00012249 Addition 0.
(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 --
Project Number
Owner's Name LAST FIRST MI
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Project Address(Street Name&Number) /,�/ / Zip—
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Applicant I Address
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City er iP ' r" �Stat
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`t/ ' /(� C' Business Phone
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Contractor/Agent Address
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City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State I Zip Phone
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Contact Business Phone
( )
Lender Address
City State I Zip Phone
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Describe Work +°nc Res. Comm.
I :_ _ &,ICE Ar)o r,oN
Subdivision/Plat Name/Shortpl tNumber
( )12)Prp-t-(riU/7-‘'"
Assessor Parcel Number Lot Block Plat Number
Pertinent File Numbers Zone Comp.Plan Census Tract
Pg–S LI r3
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
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m Number of Bedrooms
Building Technician Date Group Type
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DEPARTMENTAL REVIEW
Cond.
Approvedlgro� Approval Hold
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W. 1101 College 7'
Room 200 7/c 7
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention
o N.811 Jefferson
Other(SEPA/Critical Material/etc.)
0
❑ 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 to compile said application is true and correct.
Signature �i f' /C '�`'i..---"; ',,,7----',1--4----•"', Date -,— `,) —3- VY„)
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