1986, 08-26 Permit App: 00012832 Addition S
(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
Project Number 1'4e 3--0_
• 's Name LAST FIRST MI
a'15 � ! GZ1(2.-
Project Address(Street Name&Number)
757/1 ? > "4 �
e' (5
, A- Zip
- a. er216
Applicant �7 Address
City State Zip Phone
( )
Business Phone
( )
Contractor/Agan Address
�' � ���� /�/ " �11 � 7 �S' 9O ' /��
City State Zj Phone
44Z-X144'7"/".
tact ' ense Number(Required) Business Phone
AN "VFFI/ 7�'.D g (safe ) g2Z -�‘ c
Architect/Engineer / [3j� I � j� Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender
Address
City State Zip Phone
( )
Describe Work
}� ,,'}1T 0,0 Res. Comm.4.0"..
eest? I oetu ' /3 X2S)
Subdivision/Plat Name/Short Etat Number
(_)PPOR'Tzrov/Ty ST. ot.LIvs
Assessor Parcel Number Lot Block Plat Number
2 15172 - X40/3 (...
Pertinent File Numbers Zone Comp.Plan Census Tract
AQSti6
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
I /COD
Front Setback I Left Setback Right Setback Rear Setback RI W Width
Additional Information Square Footage
--e--.V,
# 1c o. 5c.'
I -
of
Bedrooms
Building Technician Date Group Type
T
DEPARTMENTAL REVIEW
Approved Cond. Hold
pp Approval
Environmental Health Application# 730 I 2(
W.1101 College WId
Room 200 S�
Planning/Zoning
9 9
❑ 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 con Sile said application is true and correct.
Signature ',y7" Date ,� ;1 ( — (-7.
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