1986, 10-09 Permit App: 00013944 Residence(THIS IS NOTA PERMIT) �"6q
BUILDING PERMIT APPLICATION WORKSHEET J
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)
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igject Number
Owner's Name LAST
FIRST M I
Project Address (Street Name & Number)
Zip
Applicant
Address
CityState
Zip
Phone
Business Phone
Contractor/Agent
Address
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City State
Zip
Phone
Contact
License Number (Required)
Business Phone
7W
4
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
phone
Describe Work
Res.
Comm.
Subdivision/ Plat Namelshort Plat Number
---___
---------
1-6-17-
6-'7D/
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Assessor Parcel Number Lot
Block
Plat Number
In
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size
(Sq. Ft./ Acre)
Depth
Frontage
f`
Front Setback
Left Setback
Right Setback
Rear Setback
R/W Width
Additional Information
Square Footage
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Number of Bedrooms
Euilding Technician
Date
Group
Type
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DEPARTMENTAL REVIEW
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
Approved
Approval d.
Hold
Environmental Health Application M J0
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
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Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/ Fire Prevention
N. 811 Jefferson ? �U
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