1986, 08-20 Permit App: 00012758 Residence (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 ( Pro)ectNumber Pte •,
Owner's Name LAST FIRSTT MI
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Project Address(Street Name&Number) Zip
E A 57 I LKO 1 9044, e_T— Qc53-7
Applicant Address
C. ii( l_.. n COLO-, -F'7
City State Zip Phone
�,�C;a � �..A- 99-1_0 ( > ��-v 3
Business Phone
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Contractor/AgentAddress
tC0STC,-; C .,, Alpc_s (---_-:, iii LiNQ..,C..- 2n
City c State Zip Phone
�( oLS 1. (1/- Cr) .:01- ( ) (,fo c) i 3
Contact �. License Number(Required) Business Phone
..10-p) l<os 116# i%(.. (7a- ( ) < <
Architect/Engineer 1i Address
City 1 ' State Zip Phone
( )
Contact Business Phone
( )
Lender ((�� Address
c P7144 -0 Fr;VOrr—C—ilk- .0( ,0A-^r)
City State Zip Phone _
Describe Work Res. Comm.
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subdivision/Plat Name/Short Plat Number
LE-4- [ / s r A-Da f-7-10
Assessor Parcel Number Lot Block Plat Number
21v52-- ()/5 1
Pertinent File Numbers Zone 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 R/W Width
Additional Information Square Footage
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5
Lo Number of Bedrooms
'Building Technician Date Group Type
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DEPARTMENTAL REVIEW
Cond.Approval '
Approved Hold
Environmental Health Application# &-0 7 er a '.)-0
❑ W.1101 College
Room 200
Planning/Zoning
O N.721 Jefferson
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Engineers s YW 1/37.5— ,
El N.811 Jefferson V
Utilities
O 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.
Signature Date
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