1986, 12-23 Permit App: 00014617 Relocate Residence (THIS IS NOTA HERMIT)
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
) [Prosect Number /4711
Owner's Name LAST FIRST MI
tftWaNt (C17 /1/7- X') Gey w . .
Project Address(Street Name&Number) Zip
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Applicant Address
6J-4, Q IA C'e tePe- �_eie // ." Ye):-61
City State Zip Phone
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J Business Phone
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Contractor/Agent Address
City State Zip Phone
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Contact License Number(Required) Business Phone
Architect/Engineer ]Address ��
City State
Zip Phone
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Contact Business Phone
Lender Address d 9
City State I Zip Phone
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Describe Work" Res. .. Comm.
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Subdivision/Plat Name/Short Plat Number
( 10 c v Ems rr / PLA c E.
Assessor Parcel Number Lot Block Plat Number
2b5t/S —36r7(Pru) 8
Pertinent File Numbers Zone Comp.Plan Census Tract
Acs 6
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
SD /OO
Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional) formation
r Square Footage
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2.-- Group Type
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DEPARTMENTAL REVIEW
Approved pp
Apprrovov al Hold
Environmental Health Application I �� 3 ♦ t �/ J4-
W.1101 College i),-XP ��\�4C.
Room 200
Planning/Zoning /�♦— —
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El N.721 Jefferson _ 1�� G�
Engineers /_ / 1— ,
N.811 Jefferson CO �/�� r2 �� .�- - L/
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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.
OP
Signatu - .....- dv : =_J__....1/4.: Date AZ —Z'3 g
Show on Site Plan: Additional Information: j I __4 .�._ _. .._ �..._ ._--.._._. ._.. ,^ -1.' +.--.. --Y._.- 1___ _
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