1985, 08-08 Permit App: 00006761 Addition }
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(THIS IS NOTA PERMIT)
e 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
DEPARTMENTAL the DepartmentUSE of Building and Safety)
SHADED AREAS FOR
I Project Number 6,1
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11
Owner's Name LAST FI T MI
Project Address(Street NamNumber) Zip
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Applicant Address
City State Zip Phone
Business Phone
( )
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
PhoneI Zip
( )
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DEPARTMENTAL REVIEW
Approved Cond.AHold
pproval
Environmental Health Permit Number .33 �, 1
W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson —
Engineers Permit Number
❑ 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 is true,correct,legal,and binding.
Owner's Signature _ Date
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