1985, 10-18 Permit App: 00008168 Garage, Storage (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
Owner's Name LAST FIRST MI
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4/44471
Project Address(Street Name&Number) Zip
ET:
t.0
Applicant Address
City State Zip Phone ( ) n —O U
Business Phone �+ 7'
(57 ) SL S Q ' �i"� O
Contractor/Agen Address
Ert.
City �� ��� State �a z09031-0
09� Phone
S.-4'1.—C-
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Contact License Number(Required) Business Phone /4%
foie-4* 's/ -'/'j c�/�. (SDS ) 9-26C-
City
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Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
Ass Comm.
> aeYttork4�G.�€�a m � lr?
sitodivisionli�akr, rtis� �.: ,
"if/ `�
Assessor Parcel.Number : tot Nu
4,94
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Pertinent Fite Numbers Comp Plan Census Tract
Number of Dwelling Unite Number of Buildings tot Size{Sq Ft:fActo)v / '' Depth' r Frontage l
Front Seti�a�cic t.�t ,t . �!?"i�eti ,`: . ' .,
A ditionai information i4i+are i dotage
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w.:
3
-. of Bedrooms
'Building Technician bate {croup T
42,Cy110.00.10, -° '.- -
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DEPARTMENTAL REVIEW
Cond.
Approved Hold
n Approval
Environmental Health Application# , v • ����
W.1101 College
Room 200
CI) a)I
Planning/Zoning
❑ N.721 Jefferson -
Engineers
O N.811 Jefferson
Utilitiese
O N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
0
❑ Fast Track/Special Inspection Information
Project Representative Phone
Address
I certify that I have exami -d this application and state that the information contained in it and submitted
by me or my age/to c.• •ile said application is true and correct.
ir -" /// 7�`� r ./
/lSignature i 4e4- Date
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