1984, 10-18 Permit App: 00008171 Garage 1 (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 USEi•
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Owner's Name,(
LAST /T/V FIRST ^ MI
;15-.2
Project Address -C-B Number j L 'y s--7,
Zip
7?6Applicant Address ,
EFF
/<62/ --/L7-4)17q/‘7/C-
City State Zip Phone
U.49 F 'z16 ( 51) 24--/Z-s---7
Business Phone
( 52f) /�Z2 --•=1.6'e)I
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
Describe Work a `t ` , ,-",-.,P°41'."3: a ,,. Comm.
" F 4
Svbdivlsion/Flat *I:
l Ncmber
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Assessor Flet Number `-` at t Bloat' Int Ntmaber
Pertinent File Numbers ', Zia Comp Plan Trod
Number of Dwelliirttg Llnits Nui ber of Buuildi Ft/Acre) h
-Front Setback Left digiti : �c R/W Width
Additional Information footage "
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at
Number of.Bedrooms
BulldingT Widen fate Group , Type �`
DEPARTMENTAL REVIEW
Cond.
l Approved Approval Hold
Environmental Health Application/f 6/ ,'—
W. 1101 College /
Room 200 % /
Planning/Zoning
❑ N.721 Jefferson
Engineers
D N.811 Jefferson
Utilities I
0 N.811 Jefferson
Ian Review/Fire Prevention
tVP -4'9---/.
N.811 Jefferson
Other(SEPA/Critical Material/etc.)
0
❑ Fast Track/Special Inspection Information
Project Representative Phone
Address
I certify that I have;exa ' e his application and state t+. the information contained in it and submitted
by me or my agenyto mp' said application i• : .,.—rrect.
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Signature y
Date
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