1986, 05-07 Permit App: 00011041 Residence(THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET 5�
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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 IIIVVV
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Pro ect Address (Street,Nme & Number)
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Zip
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor Agent
Address
State B ' A
IP � �
Phone
License Number (Required)
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Business Phone
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Architect/ Engineer
Address
City
State
Zip
Pho
Contact
us ness Phone
Lender
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Addres
City
State
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Phone
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Describe Work
Res.
Comm.
5+DAN
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Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number
LS5
Lot
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Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./ Acre)
Depth
Frontage
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Front Setback
Left Setback
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Right Setback
Rear Setback
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Additional Information
Square Footage
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Number of Bedrooms
Building Technician
Date
Group
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DRAWING NUMBER
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PATE: 4/41-30,..
APPROVED BY:
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REVISED
DRAWINr NUMBER
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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.
4 Signature e
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
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.
4 Signature e