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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 ( Describe Work Res...........„- Comm. /A .,,,_ ,_,�[ A1: inO j s --- A a-- ,a/ti J , ._ - _._ 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' _ t? lU Front Setback Left Setback Right Setback Rear Setback Additional Information 1-(.,t., t - a r.t=n(dt/Q Square Footage .._-.r • 1- z w I- -I' CC cx W a T4s Building Technician Date I - - Group Type p xti - B t i 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 � 1 I 1 1 i . ' 1 , , 1 1 ' • . i 1 ! 1 ' ----T --- - -1- -1-- t--- t ---t- i . , I ; - -- - -- -t - I I ! 1 • - ; 1 I J._ __,...__ .r___ .1._ • „4. i i f I I 14 i . i I j. 1 1 t • • , - EX%Tk1,JG• NOUSE t-- • 45 „, 4.• • • • - -1 ••-• -1- - "biartvio44 04kgA43%-0% - 1 11. _;- - W- 0 ,....:i.::::::: .•'-`" .. A. r 1 . / 1 @ wl ' 11 a-.4„_.,p2-(7,„ /,- . , 1 1 ).-\,...iihi....-- /.t...6 t /it- y., I PA r,u 7y f--Ai. I I ( i ..____ - -- s7 t Ps - It4 1.W • • 1 -3.0 _ �'Pr' ' 1 ________,_______7... - �. "'\-1 6 4444 - :c ;, -U 9- I . ` 1 I �1 et LO, Di / i-/ ei -z E 14 ..... 407- Y /d lotK Til /QD/ .; m - z •3 Z W i