1986, 06-06 Permit App: 00011448 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 PtdJect Number
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Owner's Name LAST FIRST MI
Project Address(Street Name&Number) Zip
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Applicant -�, Address
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City State Zip Phone
Business Phone
Contractor/Agent Address
City State Zip Phone
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Contact License
Address
Number(Required) Business Phone
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Architect/Engineer
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City State Zip Phone
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Contact Business Phone
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Lender
Address
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City State Zip
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Phone
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Comm.
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SLot Block Plat Number
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its Number of Buildings Lot Size(Sq.Ft./ACF e) Depth Frontage
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Square Footage
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max a) Number of Bedrooms
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DEPARTMENTAL REVIEW
Cond.
Approved Hold
Approval
Environmental Health Application# • 6,tigee
W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
tig N.81111Jefferson wOs. QST(4C( OP-U
Utilities
D 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.
Signatur- / -: --� Date
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