Dishman Mica S 814 Hoffman Contractors - Shed
(THIS IS NOT A FIERMIT)
BUILDING PERMIT APPLlCATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOD UNDERST"ArvV
COMPLETE IN INK
(Please return this Or►ginal and your building plans to the Department ot Building and Safety )
SHADED AREAS ARE FOR DEPANTMENTAL USE
~ PtOject Nurnber
Owner's Namd LAST FIRS7 MI
Project Address (Slreet Name & Numoe►► Lip ~
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Appl iCBnt A~fc1r ess
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City State - Tlp Phone
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- - - Businexa Phone - -
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ContractorlAgent ~ AbQresa
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City State 2ip Phone
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Contact License Numbir ~Aequire0) Business Phone
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Arcnitect! Engineer ; Adaress ~
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C'tY - - State _TZip 1 Pttone ~ - - - - - - -
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Gontact --FBusiness Phone - _
LenOer ~ Addres9
Gty State Zip Phone ~
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OsocNbw Work Aee. Comm.
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Subdivbbn/Pyst NarnelSllort Plat Number _
/rssasor Parosl Number Lot Biodc Plat Number
2os44 3-~olq
Pwlfnent File NumDers ZCanp. P4an ~ Census Tract
Nurn6K a ~ unia I Number a 3 ~nps ~ l.a sins ~ Ft. Zr Acre) ~ Uvpt~h~ r 1-~ f Fro ncaa~ t
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Front SetDedc ~ Lafl Ssth-clc - ~ AiqR1 SetDack R/ W W!dtn
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SQua ootape
Addltionid (nformttfon
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m Number of 8edro0ms
8ulldlnp Technician Da1a Group ~ Tvae
it)!A YY1 . 11 5- 13- z 1\,/
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DEPARTMENTAL REVIEW
Approved Cond. A proval Hoid
I~ Envlronmental Hsalth Applfcation l~ ~L~ l~ u
X-x W. 1101 Coliefle ~
Room 200
Plsnnlng/Zonlnq
~ N. 721 Jefferaon
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En9lneon
N. 811 Jefferson
Utllitl" I
❑ N. 811 Jefferson ,
Plan Revlsw/ Fire Prr"ntlon
~ N. 811 Jefferaon -
~
Other (SEPA/Critlcsl Mststlel/etc.)
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.
~ Fast Track/Speclal tnspectlon Informatlon
Pro)ect Repreaentative Phone
Addresa .
1 certify that I have examined this appllcatlon and atate that the information contained in it and aubmitted
by me or my agent to compile said application ia true and correct.
f% x- F A? N"-,' C'c
Siflnature o8 v° Date
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