1986, 08-13 Permit App: 00012621 Relocate Residence, Addition (THIS IS NOT A 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 Project Number ff f„/7
Owner's Name LAST FIRST MI
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Zip
Project ddress(Street Name&Number)
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City 1 State Zip Phone
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Business Phone
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ContractorlAgent Address
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City State Zip Phone
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Contact License Number(Required) Business Phone
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Architect/Engineer
Address
City State I Zip Phone
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Business Phone
Contact
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Address
Lender
City ' State -_ - — I Zip Phone
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Describe Work 'SL Res. / Comm,
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Subdivision/Plat Name/Short Plat Number V X r
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Assessor Parcel Number Lot Block
Plat Number
Pertinent File Numbers Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft /Acre) Depth Frontage
Front Setback Left Setback Right Setback , Rear Setback R/W Width
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Additional Information .. Square
nformationSquare Footage
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DEPARTMENTAL REVIEW
Cond.
�/ ,Approved Approval Hold
Environmental Health Application# �Z— 7 ,r„ _
DidW.1101 College
Room 200 ` -- (-7,1;
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7 Planning/Zoning
so. X N.721 Jefferson )1407=
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yilEngineers // i SIiT/�
N..8111Jefferson -fes i `
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Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
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.
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Signature ,..11-vii„.‘ 7,1/4 Qi (f�' '"l Date
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