1986, 01-23 Permit App: 00009458 Addition (THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
r
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
Owner's Name LAST FIRST MI
•
— )
*e.%
Project •ddress(Street Name&Nu Ir r) Zip
77i / - , J
Address
Applicant
'Il y /1. I'l {7 a !) p '�C_ .-. l[i A.J
ZIP Phone
( 7241 -,e)() e
Business Phone
( :.>f) -166
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
1 ( )
Lender
Address
Phone
( )
.-
.-PP---,-.`rz lifillillilMaill State
• a g�s .' -� � a � st r s
,rt
a " a Prt x ,... '` , ,,". + :r Ttx
' .
� wr"3r.ate a' ea�.t�a� rx*g:r� ... �," � � ��d�Rtu.. a� 's:�?.n:r'la�+� ,= x C
e ce Z . "''' i-• k � �. �� ': ° ;fit `:. 4k ' t: s +V- , ,+�[ L .'
t+� .e$t ,<.:T'`t - ram �:Q.1 'mc5 :::�* :.: ii " .-2,, 5 'P t `� *4...'°k: it
§ e 3 t$., - { : ."' ' ~ TSF
T°'14'11.11s,x .-2' r ,Zu,� it, - � � �k F' "b rw' `a . §
i".1�'.�,ted kY§F - k
x
kap ark xa
. d+ r a 'a ,s R � s s �� � 8t da3 ?�s��, i °aa„a,' $ fr` = c p t
r x ' '�xy. $ rd. x aa„, �f .y a 6 :% a T
i5 d ,'k`i '.%'.=','
1 a L t S,t�p a°Sd`A P- —
� ,3, � x" tad�' • •'1,•'L•':-.1.'"f14, Baa, 'p �, S�
a Pax. a � %„k § +�,` ,'i 't .r-"a,:Ft#�r
r.
r x ?z,„ ' „ Watt ..•'+'''.7=v;+•%'-'=”' •.•a'.,+ ,�z- �r ".sd°` � k `a
�, .. � -'^- mgr:.
�r . '
-� 7 �� ,� a r 4 � ' { ..� i' sea4 � '" m1 �x,. iy 4160r'r ;•.- ,
kv,p,..,4, , s I"j8Rr >T x�
i
n
,
DEPARTMENTAL REVIEW
ved Cond.
(oley*stApprovalEnvironmental Health Application ff /1613/W.1101 CollegeQ�Room 200 ) le'
/1— ,i/vi)(;/ f
v ' g94121rettr-/'e *41 4 4rvir .
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention
N.811 Jefferson 3u J.�67 -Co Csi 6--o
t iNS-ec t O r_,J
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 and correct.
Signature --fes Dat 3 (7: - P6
‘
— .,
., .
— ( 1----4\
.. .
!
J 1
J j
, ! .
, .
i.,
. !
. ,
, ., Ne .
1 tfirr-p—
I J
...
0.- I
9
n
, ac i
I .._..P
ii
1
E ( / 3V