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1986, 03-17 Permit App: 00010190 Duplex(THIS IS NOT A 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 Project Number Owner's Name LAST FIRST MI 1 Project Address (Street Name & Number) Zip E. i d7 02- o 4 z a-rj" Applicant �0o Addr ess /tea/ S 11 e Cef . � , _-_I- City State j Zip Phone Business Phone Contractor/ Agent 61ee A I Address (I k, �Z _7— City State Zip Phone Contact License Number (Required) Business Phone ,�� Z a� / t ) Architect/ Engineer 10-7 Address City State ---:: Zip Phone ( ) Contact Business Phone Lender Address City State lip Phone ( ) Describe Work Res. Comm. Subdivision/ Plat Name/Short Plat Number J—T {61KOnI C> 1OWhe, S Assessor Parcel Number Lot Block Plat Number f4S2z, ,, Ix- Pertinent File Numbers Zone A&S(A o Comp. Plan Census Tract Number of Dwelling Units Numberof Buildings Lot Size (Sq. FtJAcre) Depth Frontage Front Setback Left Setback { Right Setback 2G' Rear Setback R/ W Width —i 4 ` 2 40, 9 ' Additional Information Square Footage 087 z F - X XXL Z o o- z_ z 0 J_ m Number of Bedrooms �Bu�lldlng�Technician Date Group ry Iz 3 011 N A E 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 Cond. Approved Approval Hold Environmental Health Application # �-` � W. 1101 College Room 200 t Planning/Zoning N. 721 Jefferson Engineers N. 811 Jefferson Utilities N. 811 Jefferson Plan Review/ Fire Prevention N. 811 Jefferson tS 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 o