1986, 12-02 Permit App: 87000042 Residence(THIS IS NOTA 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)
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Number
Owner's Name LAST FIRST M I
CN --1
Project Address (Street Name & Number) Zip
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor/Agent
Address
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x
City
State
Zip
Phone
y
Contact
/�
License Number (Required)
Business Phone
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
Describe Work s -
Res. Comm.
Subdivision/Plat Name/Sh?rt Plat Number
lessor Parcel Number Lot
Block
Plat
P Number
P
Pertinent Re Numbers ,
Zone
Comp. Plan
Census Tract
umfTef Dwelling Llnits , Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
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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
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers /
N. 811 Jefferson ( — /Z�?o ell
Utilities
N. 811 Jefferson
Plan Review/ Fire Prevention l
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