1986, 09-17 Permit App: 00013166 Garage (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
l I Project Number
Owner's Name LAST FIRST MI
Project Address(Street Name&Number) Zip
7r`�
Applicant Address
n
q505 11
ra I �3oy
City tate , Zip Phone
1
City
NiC— (1,- A EI`ie: 7 (SO ) Oici
Business Phone
( )
Contractor/Agent Address
City State Zip Phone
- ( )
Contact License Number(Required) Business Phone
I. ._ SI CKA6. ,, i'( 7k id ( )
Architect/Engineer Address
.... /z1/57
/z1/g7
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
Describe Work Res. Comm.
A-`r --Ae 4G0 4-RAG-e--( . 2. ) '>
Subdivision/Plat Name/Short PI Number
\f/Oirisn 00
Assessor Parcel Number Lot Block Plat Number
735"111/ a'r,
Pertinent File Numbers - Zone
Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
/ I //QS
Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
Z
O
H
Q
2
Q
O
U-
z
az
Z
5
J
5
m Number of Bedrooms
Building Tech clan Date Group Type
F
4
4
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application#
❑ W. 1101 College
Room 200
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 to compile said application is true and correct.
Signature r Date —514 1 / j
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