1986, 08-19 Permit App: 00012788 Addition, Garage (THIS IS NOT A PERMIT)
A - 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
I Project Number
Owner's Name LAST FIRST MI
iJb A/20 i
Project Address(Street Name&Number) Zip
!;;4QS7— /4 i 2 /(0 774- Avg QQO37
Applicant Address
City State Zip Phone
( 9) Qz.4L--(,5;7
Business Phone
( )
Contractor/Agent Address
3ArL
City State Zip Phone
( 1
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State I Zip Phone
I ( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
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Describe Work Res...........„- Comm.
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Subdivision/Plat Name/Short Plat Number /4"X IQ) (J(o X2:4)
otAt ra-°`(` A-1) 41-I.S 11-D,0
Assessor Parcel Number Lot Block Plat Number
Pertinent File Numbers Zone br r. Comp.Plan , Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft/Acre) Depth Frontage'
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Front Setback Left Setback Right Setback Rear Setback
Additional Information 1-(.,t., t - a r.t=n(dt/Q Square Footage .._-.r
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Building Technician Date I - - Group Type
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DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
AEnvironmental Health
W. 1101 College Permit Number—73 I 3 S7 1
Room 200 g /if'ii
Planning/Zoning
❑ N.721 Jefferson
Engineers Permit Number
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson I
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 • •ent is true,correct =' al,and binding.
Owner's Signature - r / i4Date �
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