1986, 06-30 Permit App: 00011974 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
Owner's NameBAST FIRST MI
resit-1 ��r ` `
Project Address(Street Name Number)1 V Zip
r ( 4g34c D � • //
Applicant Address
City State Zip Phone
( )
Business Phone
( )
Contractor/Agent Address
1(C'Sl (-11':.(it'l ' k o E.- 111 'l;n Iry a' .
J.
City State Zip Phone
5cv w 99 2-,72S ( ) '1(•(..,--. 13
Contact License Number(Required) Business Phone t `
\(c is 1. 41 I�U A ( )
Architect/Engineer Address
—
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
iti-Ft
City S��" State Zip ���� ( Phone ( ) 4 309--c:
Describe Work * - 11(15 W y.:CA V Res.Comm.
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Subdivision/Plat Name/Short Plat Number
14' 1sf p4Pt.tioNA _- _
Assessor Parcel Number Lot Block , Plat Number
2__fp g4 Z 1
8013 0! (rois� t
Pertinent File Numbers Zone Comp.Plan Census Tract'
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
(. i $A.,‘ '01: 2,2...
Front Setback i Left Setback i Right Setback I Rear Setback Rt W Width
;Z IS 20
Additional Information Square Footage
IIF .- {2612.
ff
z U$ = 12.6,o
0
Ft 6Aer, . 52-e)%
2
cc0
u.
z
o
z
0
0
LCI Number of.Bedrooms
Buildi g Technician Date Group Type
uiYl 6� � 63
.
DEPARTMENTAL REVIEW
Cond.
A.pr• ii` ' Approval Hold
�/
Environmental Health Application# d v 0 1 (,60
❑ W.1101 College I/�1
Room 200 ��
--'.'74-11.1-17 etttlArldlid r/ ‘,/— ,%ii '
Planning/Zoning
❑ N.721 Jefferson
Engineers �/ 44 /�,
3O
❑ N.811 Jefferson 4
Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention 7--(--s
❑ N.811 Jefferson g(11
Other(SEPA/Critical Material/etc.)
LI
❑ 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 m agent to compile said application is true and correct.
Signature ane Date L-3cd-- "
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