1985, 05-20 Permit App: 0005491 Siding BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name /f `/ (last) (fir )'�,,// y�/�(m)gyI Department Use Only
k
/tJ(1f 1 0 e� /. / K / / r l 143S. ✓ Comm
2 Project Address(not iling Address)or Road Name t Space Zip
/31/0 7 3 ' g'q271�
3 City/Co unity State Subdivision/Plat Name
) <��fi� C�(1!� very
4 AssessorParte No. Lot Block
2 -2.22-7 . . * DEPARTMENT USE ONLY * * *
5 Sic Code ¶neAct.#
Zone �� Project No. 51-/g/
6 Dwell# No.of Buildings Sq.Ft./Acre Depth Frontage
1/4/7
7 Set Back-Front I(L)S-1 (R)S-2 l Rear Census Tract Module No. Initials
f
*
* 16 Architect Firm Name I Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Contractor Firm Name Street9ddress
i71/?G(A �/L- 0)/A ( /ids AY- 5"
/3 V a l' 3'`A
Zip ! City State Phone
( ��� (Tog) �2 - mm�
Con n 1 License No. Phone if different than above
it, Inc a Gfi C 04 K(Se L3V n76 ( ) J6.9-w
8 Owner/Agen (if different than#1 a ve) Business Address
9 Zip City State Phone
( )
12 Review Required Plan Check(Y/N) Other(Y/N) [SEPA Exempt(Y/N) Date
15 Type Work ❑ Bldg 0 MH ❑ New ❑ Replace iRt, Other
❑ Fire ❑ Demo ❑ Add/Alter ❑ Move ✓epa/r-
14 Describe Worki ) r
Fa‘5,
10 Applicant Name U "Street Address
11 Zip City State -Phone
( )
* Lender Street Address
Zip City State Phone
( )
Contact Person Phone if different than above
( )
Additional Information
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