1986, 05-28 Permit App: 00011264 Shop • (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
Projedt-NuniVer... . . . t
All
Owner's Name LAST FIRST M!
4444' .7/;41-,0-74 __O-_____
Project Address(Street N%buer) 9I,i �/ zip
Applicant/ e-iike,96SI--- t0!C /'/T�- d
I�s/ .5- 6 7 - --lit
City State Zi Phoo-e �f
�'/ Business Phone
( )
Contractor/AgentAddress
,570,--/,-/-6.
City r State I 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
i
Describe Work Res. / Comm.
Subdivision/Plat Name/Short Plat Number
(CkeDwAro PAric--
Assessor Parcel Number Lot Block Plat Number
225273—672 7 7
Pertinent File Numbers Zone/� e Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
sem-- /V.j: lWD
Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
I
Z
_O
Q
2
cc
O
U. _
a
z -
O
I
J
m Number of Bedrooms
., !•‘`':;)-. ,.:.'''12.:',3 - Date Group Type
7F(77' fid- 1 �l N1
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DEPARTMENTAL REVIEW
Approved Cond. Hold
J /� Approval
Environmental Health/
Application# / 7 9 `�'_ ."..._et,
W. 1101 College , • ` . /
Room 200 X40- . /� ._
`--AD y•eatkii ,iit/ciil,
4-8/ / Li
Planning/Zoning
❑ 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 compile said application is true an correct.
17 /I' 41e/eY
Signature / 'ce ( ` / G�7 Date �/
/1.4/
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