1986, 06-30 Permit App: 00011971 Residence ` s (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
: ri. �.44,r • . er�*§ : est
Owner's NLAST 1.--- FIRST MI
Project Ad ess(Street Name&Nu ber) Zip
C.4cT /1/531 �:
Applicant Address
City State Zip Phone
( )
Business Phone
( )
Contractor/Agent Address
Kosf �.).Lo�-,�S L: tir L`„CaL 0.
City Sta a Zip Phone
� � �ii ( ) 4`G`-0 s i a
Contact r.-- License Number(Required) Business Phone
Jale-1/4-1 9C%:=. - 6 1 a(e,13/4 ( ) Sem
Architect/Engineer Address
I.) A
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
S'?'A,•Ircf:)../17 V-th,JNA-4,K:,:i AL
NV41)• i's-►Z D
City State Zip Phone
Describe Work{ Res, Comm.
i ,/ i SCE w . ( PACE
Subdivision/Plat Name/Short Plat Number ,,
LN I / S--
Assessor Parcel Number
—' Q6 �� .2.. ...,
�Lot Block Plat Number
6047
Pertinent File Numbers ,„ Zone Comp.Plan Census Traci
Number of Dwelling Units Number of Bulldinos BuildingsLot Size(Sq.Ft./Acre) Depth Frontage
/‘6so
Front Setback sv Left Setback 0, Right Setback Rear Setback R/WWidth
Additional Information V ffLL7J Square Footage
1 9S7 = I`-1
Z 1 / 1-7 —` bre
0
a .,. ..B -- QA P.
2
o hilt= Clove
z
z
s
J_
CI Number of Bedrooms
Building Technician Date Group Type
Y
e • i
DEPARTMENTAL REVIEW
Appro ed Cond. Hold
/i•prove!
Environmental Health Application N r6 77
0 W.1101 College - /,�'
Room 200
GL-771. 74)-2,—//7" --it
74) I� "
e"-e& .
Planning/Zoning
0 N.721 Jefferson -
40 , I.
Engineers
El N.811 Jefferson -Ztelw& 34f -'-'
Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention 7-32,4f°
❑ 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 .gent to compile said application is true and correct.
Signature W 7� Date `40— r3,
1 - --
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