1985, 11-12 Permit App: 00008716 Duplex r
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' , (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)
SHADED AREAS ARE FOR DEPARTMENTAL USE I project Number
87 1(47,
Owner's Name LAST FIRST MI
W(n �
Project Address(Street Naaye&me&Number) r� Zip �
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Applicant '//% /4- �_ 7—/4 C ! C./
• Address t ` ' `
11W
CityState Zip Phone
_ ',74 e "Z#114/2T 9'92/0 L..5w. 92-e_ -----7_S 0
Business Phone
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Contractor/Agent Address
�� ms 's 77 /�C' ; /t
City State Zip_ Phone
( ) J
Contact - License Number(Required) Business Phone
Architect/Engineer , 7 )(1/ 9/ 2,1 /6-14)
/L,[) Addres �� ���/et()
City State Z/7,-5//—
�//f Zip - 2 Phone
(--4117 4S14
ContactBusiness Phone
Lender Address
City '41/e- . State I Zip Phone
Describe Work Res. Comm.
17)
0-P,LE CoE 7e C A A) C `- .
Subdivision/Plat Name/Short Plat Number
Assessor ParceCumer Ca /CU,'ki e7 �kA q 'f f d f'F it,-;-- -3)*
)* ?'sC
-4-to 4lo
Lot Block Plat Number
-'5
;''- 9/1/ ' / pl Q4/' 9 1/
Pertinent File Numbers "Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth / Frontagt:.,n
11,
Front Setback n Left Setback Right Setback Rear Setback R/W Width
.`-5 7
Additional Information (r,- ft-r Square Footage
TC' _
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m Number of Bedrooms
Building Technician Date Group Type
// '! - t 0\1
s
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application# /I 1LZ:1___ • -1,z'.91c'
W. 1101 College L{4
Room 200
4444.;(.., 772,1,4_voy % . ( 6e.. Pm°P.1E
Planning/Zoning
N.721 Jefferson
Engineers IW11 9 d
N.811 Jefferson /Utt [HT1
-----
f°..-
Utilities Utilities I
❑ 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 corn ile said appiicati•• '; true and correct.
fi
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