1987, 02-26 Permit App: 87000409 Reside p`1/` (--"f761-44-7
(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 USE
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Owner's Name LAST FIRST. MI l
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Project Address(Street Name&Number) Zip
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Applicant Address
.d.c.2aa 6 Yi. v 61-4--/L9 e / /9a 3_ /0 )1.-_4
CityState Zip Phone
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Business Phone
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Contractor/Agent Address
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City State Zip
A ( 50
Phone
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Contact License Number(Required) Business Phone
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Architect/Engineer Address
City State [iiip j Phone
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Contact Business Phone
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Lender Address
City State Zip Phone
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Describe W Ree. Comm.
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Subdivis /Plat Name/Short Plat N um /�—
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Assessor Parcel Number Lot Block Plat Number
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Pertinent File Numbers Zone Comp.Plan Census Tract
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Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
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Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
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CO Number of Bedrooms
Building Technician Date Group Type