1986, 08-13 Permit App: 00012622 Garage (THIS IS NOTA 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
IProject Number
Owner's Name LAST FIRST
MI
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Project Address(Street Name&Number) Zip
V-. t 3cY7 - 16tl eAc)ActS1e f wcfr cfc7v 37
Applicant Address
1\) X09€ 14. NIV R TH. I _. 15 ?)c7- 16rth
City State Zip Phone
yelOACtcQ Luc, . 9gD37 ( Szih q£ 4 - 1 40
Business Phone
( ,uq ) t �2 - tco( Eft 3 . 36
Contractor/Agent Address
City State Zip Phone
Contact License Number(Required) Business Phone
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
Lender
Address
City State Zip Phone
( )
Describe Work Res. Comm.
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number Lot Block Plat Number
3 1 7 1
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
Additional Information Square Footage
Z
O
H
2
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O
2
C3
_Z
O
-J
D
CO Number of Bedrooms
euildi�g Technje� J �/ Group�t fl yPe
a
DEPARTMENTAL REVIEW
Cond.
Y'Aapproved Approval Hold
Environmental Health Application# . . 0 ,sP"r
w.1101 College " / �,
Room 200 •
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Planning/Zoning
El N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
CI
❑ 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.
Signature Z.tt� 1L'11C .rviVaLs- Date .�/ � 3/ LeO
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BUILDER
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( Ci) 924-6133
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