1985, 09-30 Permit App: 00007774 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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Project Number -7'7 -1 G
Owner's Name LAST FIRST MI
Project Address (Street Name & Number) Zip
Applicant
Address
City
State
Zip
Phone
-3Z- 3 S�
Business Phone
Contractor/ Agent
Address
r(�
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
Describe Work
Res.
Comm.
✓
Subdivision/ Plat Name/Short Plat Number
Acres
EK-4fI&C'e-)
Assessor Parcel Number ` Lot
�?
Block y�
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./ Acre)
Depth
Frontage
1
1
/5G,
PC
Front Setback 35
Left Setback
1
Right Setback
Rear Setback
R/ W Width
Additional Information
Square Footage
rnE 129E
Z
0
—
a
0
t,
Z
Z
0
J_
M
Number of Bedrooms
Building Technician
Date
Group
Type
ic
FEW
01
0
N
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
pproved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
L I
Plan Review/ Fire Prevention
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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PO
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