1986, 06-30 Permit App: 00011976 Residence (THIS IS NOT A 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
fl o1 tNumber 4i4,(.,;.\--7. , e .,.
Owner's Name i LAST FIRST MI
t�S' k-` -t L rr J
Project Address(Street Name&Number) Zip
Applicant `y„CJ Address
City State l Zip Phone
( )
Business Phone
( )
Contractor/eent � , Address _
5.% .Locrz.s L,
. i 1 t , , e o
City cilerkese_ State Zip Phone
w 9C CF ( ) 1/4-41-cA 13
Contact Lice Number(Required) Business Phone L
Architect/Engineer I Address
City State
Zip Phone
( )
Contact Business Phone
( )
Lender Address
S.'"I"P`iLi 7 0 c.'%)ttNI4C.-k A-1.---- l' )'' Hz t, arrt..D
City t State Zip Phone
It f''214. Lot/N 91 2t;. ) ( ) '$3�' — ss-I. i
Describe Wo / 1!`
12-5- 19 . ---i\\t/� I Cv `.0,L Res. / Comm.
Subdivision/Plat Name/Short Plat Number !//! �/"
LELA- t Isi P401-ct0f',
Assessor Parcel Number \ Lot 4--1 Block Plat Number
�(' ✓ 'J r` 013 � (lf ( �k�r` .;,,I
Pertinent File Numbers 1 1 Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
1 1
Front Setback , Left Setback I Right Setback 1 Rear Setback R/W Width
Additional Information Square Footage
2
Z
oz
0
J_
5
m Number of Bedrooms
Building Technician Date Group Type
_IN o . 368&
DEPARTMENTAL REVIEW
Cond.
A•p ove Approval Hold
Environmental Health Application M d I16.
D W.1101 College
Room 200 I /J
#7,62.„.74:7,66
Planning/Zoning
❑ N.721 Jefferson .
hrfr'er,
Engineers
03
❑ N..81111Jefferson
,
Utilities
0 N.811 Jefferson
Plan Review/Fire Prevention -Z-
❑ 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 my agent to compile said application is true and correct.
Signature Date
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