1986, 10-17 Permit App: 00013942 Duplex (THIS IS NOTA PEFMIT)
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
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FIRST A) MI l,`
Project Address(Street Name x N mbar) ,^K/-/Y`/,I JT/JAr/G'-- Zip
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Applicant ! Address
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City �� State CN / Zip ��^ / Phone �,^ ) 9ZZ z-70e
G- Business Phone `�
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Address
Contractor/Agent
C State Zi Phone
Business Phone
Contact License Number(Required)
Alitiem
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Architect!Engineer Address
City State Zip Phone
( )
Contact Business Phone
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Lender _ Address
City State Zip Phone
( )
-
DescribeWo lt, Res. Comm.
-Subdivision/Flat ►ant nort Plat Number
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AssessorParcel Number Lot Block Plat Number
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�{ anent lumbers Zone Comp.Plan Census Tract
Number of Dwelling Units •Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
i •` -': Left Setback t Right Setback Rear Setback • R/W Width
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DEPARTMENTAL REVIEW
Cond.
- Approved Hold
Approval
Environmental Health Application# �l(c� l r /a-/7
W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers 7N.811 Jefferson
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Utilities
❑ 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 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 afged-464----"' Date Id —/7 ^8.61
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