1985, 07-24 Permit App: 00006524 Remodel (THIS IS NOTA PERMIT)
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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 ��4n
Project Number ..
Owner's Name
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Project Address(Street Name&Number) Zip
Applicant Address
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Zip
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City State Phone
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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
( )
Contact Business Phone
( )
Lender Address
City State Zip [Phone ( )
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DEPARTMENTAL REVIEW
Approved Cond. Hold
pp// Approval
el'Environmental Health Permit Number 4Ub 7-
W. 1101 College ✓/
Room 200
0 d di 144 1..1•/0 erl ,d/&‘1)111146://70) efit
Planning/Zoning
❑ N.721 Jefferson
Engineers Permit Number
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
111
❑ 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 is true,correct,legal,and binding.
Owner's Signature Date