1986, 03-06 Permit App: 00009926 Garage ... Z 3c44 - O‘09
(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
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Owner's Name LAST FIRST M I
Project Address(Street N-me&Number) i. Zip
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Applicant Address
City State Zip Phone
( )
Business Phone
Contractor/AgentAddress
City State Zip Phone
Contact License Number(Required) Business Phone
Architect/Engineer ( )
Address
City State —
Zip Phone
ContactBusiness Phone
LenderAddress
City State Zip Phone
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DEPARTMENTAL REVIEW
Cond.Approval Approved Hold
id Environmental Health Application# 040
ISI W. 1101 College
Room 200
Planning/Zoning
El N.721 Jefferson
Engineers
El N.811 Jefferson
Utilities
❑ 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.
Signature Date
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