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1986, 05-23 Permit App: 00011203 Addition
Pik (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) SHADED AREAS ARE FOR DEPARTMENTAL USE 1 Project Number r , J Owner's Name LAST FI RST M! Ofd U( S 6-c_ou- J € Project Address(Street Name 8,Number) Zip Co 1-/O E s * 7 '' Spe C`�0uw�7 Address Applicant �p C-7- eo�' e DrJ`.0-/t. Ge— oeua( C c.,u$1, 1 14) / $-z — ocif 0u,! City State Zip Phone 41. r. Li &) 4l J-20 6— (507) 3as- /ecce Business Phone (3o?) 32r - S7/ Contractor/Agent Address �7-eUv-c� e_ 0 © (NcLrJ City State Zip Phone :_ k._,L,,,,_.c L) t ?q9 a C (1-0 9 '.a_ k / r Contact License Number(Required) Business Phone \ Ggo ,G DG- 177 w (3•Q ) 3 r --- 7/4- Architect/Engineer Q Address v City State Zip Phone ( ) I Contact Business Phone ( 1 Lender Address j City State I Zip Phone ( 1 F Work y// /I �+ ^ �j^�, 1(/. Res.V/ Comm. 41 16 bi ion/Plat Name/Short Plat Number -I 1OOil � r Parcel Number Lot Block Plat Number Pertinent File Numbers Zone, Comp.Plan Census Tract Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage t Setback I Left Setback Right Setback Rear Setback R/W Width : f61i1 ivLr' ..itional Information Square Footage Z 0 4 2 cc O Li. z n 0 5 m Number of Bedrooms Group Type ,f �Cr 3 vN -, , I I . . 1 . .! .. I . 1 , . , f • . f,.. .. . .1 .. /. .e -". I. . - I r),1 - -1c-!/).,j,IV‘I'zi - I" - . - I • 1 • 1,•• -1 - I !!!" - •• .. ;,I ••• - ‘ ---7,---it- i/! I 1 • . 1 ! ! . . . 1 !I.. I . ' : . • - . i 1; : y• ••; ,. ---..4..../. ;..,_1::.• - •• •--;. /-6-.-.L.,: •-0-I-t:o•:.-',,.-)k ..-../.... .- 1 1:--.. -.-- .1.:,- ' .•I 7 ... . -I . .!! • • 1 ! . 1 . ! 1 !.1-. - •• :•*if A-""1 •' 1). .! ! • .1- • I • I i // 4 1 1 I '• ' 1 -I • ' '', -'tie --P, al' 0 !)/ ;/ , , ' -• 7 -t : i i I i I i i I 1 1 ! i ! , ' ' , : , ' ' ', ryi I'.,_ 1,';'i-.1- '- • ' ! -1- -',--1 ,-...L.4...:-.::4.:' ' :I: .4. -•- - 4 L'• i ! --1 ---1 --i' i--- --. 7 ± 't i'- ! , I ! ;! - - . i ! ' • • 1 ! : : i • = I I I , ! 1 1 I i i 1 I 1 I 1 ' I 1 , ! I ! i 1 I I I- - 1--- 1--- ' 1— I + 4 ! -4-• - i ! f- t„ I Tr' -- -I! 71- 7 - '„ 1„ a'! „ I 1 I • 1 ' • 1! I t ! , 1 '11 II -41 ! ! -t---!-- 1 1 1 1 -1 ! 1 I ! .4.- .4- t h! — t - ! ! ! ! - 1 ,.„ ! ! !! ! 1 ' ! ! i ! ! ! • ! I i, .i i I. L --- ' 1 - 1 -- - ' r - --F .1-3-c --i-s- -. -1 . . , - I IIF 1, i i._ A : : _ , , 1 . 1 ; 1 i 1 1 1 1 1 i t 1 1 f - [ ! l 1 l . 1 1 • 1 1 I; " 1 1 : . ' I 1 - •-• I 1! I I I I , , , .4_ : . ..• i I I ! I I I I ! ! .L.----. •.! -, !! 4- -1- • -* - i II '• 1 „ , 1 I I . , 1 111: : 4__ 1 :, . f- I ,1 1 I " : , i , • ; 1 t . , il ---t- — 4- --f 1- • I 1 I ii : Hii • - • i : : , , -1 I _ I, _±.._ 1 -f- -. 1- k\INi III .) -I-cliI I I1! —1 ; ! _...L._ L + • I i '-lis--- ,e1- I ----t---1-- t------- T 1- 1 1 f-----T • 1, [ i , 1 , i i I 1 i t lit—--f I --f• I I I I 1 ' I 1 ! 4' 1 -4- , , , , —.. _ _•______i ._ - --ttr,Li - I , i i 1 ! 4„ 1 1 ; - II i i 1 1 1 7..1._. .....,__...ft_.]!, I 1 It ! T L\ . t- 1 /10k4)1 I ' 1 sl 1 ! 1 I 1 I I 1 I I HH I ! . ___1 _ L i .,,, 1 -H, , f 1 ! 1 1 A4doi-,..t 1 i N • t-; 1 -- 1 ii _ i 1 I I II 1 -- t ' --I —1----ri 14-?i 1 1 1 -i-- i -- 1 i i I i i 1 I 1 I 7 . , -47771 1 Hi I ----r- i -Fi ---i- I 1 i i 1 - 1 I i • i DEPARTMENTAL REVIEW Approved Cond. Hold - Approval Environmental Health Application if cc S 4.- C ❑ W. 1101 College Room 200 l•- IL(../ T Planning/Zoning ❑ N.721 Jefferson Engineers ❑ 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 compile said application is true and correct. Signature Date CZ /e6 �