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
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Addr ess
/tea/
S 11 e Cef .
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, _-_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