1986, 06-20 Permit App: 00011783 Addition CI 51)
(THIS IS NOTA PERMIT) I 0
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
___1(410/ I
Project Address(Street Name&Number) Zip
E l7haa, 6 71- k'ei-itizic. S f 2 o r b
ApplicantAL'YLEI ' 76 ✓ '1 . Address
City S12ekAtniS State (A) Zip Phone
Business Phone
( 5 ) To.$- 73 /
Contractor/Agent G Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City j State I Zip-— Phone
I_ 1
( )
Contact Business Phone
( I }
Lender
Address
City State Zip Phone •
(
Describe Work_ ' t
7 I c,� X} 9 /� !L-'!� /� Res. Comm.
X----
i
I E /AV.9S,i.. .. 4-0E/14,)(s, 0/.6 thNtlt�(1.4O/►`. ,T7v 4j o/�P 'Cic'2,
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number Lot —'1
5c1 K olol � Block plat Number
Pertinent File Numbers Zone
Comp.Plan Census Tract
AcvaA •
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage t
Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information , Square Footage
IAT u��1. - 0cia0 'DO m F _ 1228 37p = 12tX (c( )
GI
25 = 226 z $$-L Eiu.)NG
M C = 2-1-0
a
2
cc
0
LL
z —
0
z
0
J
5
CO Number of Bedrooms
Building Technician Date Group Type
..N Ni 41) . 6, "lob~ (0 12'- VN
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
p1 Environmental Health Application N / ,4/
College
Ro f �� .,
Roomm 2 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
o 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 to compile said application is true and correct.
Signature Date
or
C
G`k A i`
.
C-.)(1 -1-1 NL
t dr&X •
u PRG 1(1441°S6 l
IL
1"?
.
r
41
f
I
0
r
;
I ,
1. ! _�
i1 11 , i_ r I
G
1
1
}_.
I
1
1 1
• i
1