1986, 01-23 Permit App: 00009650 Residence(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)
SHADE
D AREAS ARE FOR DEPARTMENTAL USE
Project Number
Owner's Name LAST
FIRST
MI
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170's E'
Project Address (Street Na e & Number)
Zip
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Applicant
Address
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City } j
State /
Zip
Phone
Business Phone
Contractor/Agent
Address
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State {G^� }�
Zip �L�
Phone
Contact
License Number (Required)
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Business Phone
Architect/EngineerAtltlfess
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City /
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phene
Describe Work
}-
Res.
Comm.
Subdivision/ Plat Namel Short Plat Number
Assessor Parcel Number Lot
Block
Plat Number
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Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft.IAcre)
Depth
Frontag�e'
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Front Setback
Left Setback
Right Setback
Rear Setback
Rl W Width
Additional Information
Square Footage
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Number of Bedrooms
Building Technician
Date
Group
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DEPARTMENTAL REVIEW
Approved Cond. Hold
Approval
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Environmental Health Application N G51
W. 1101 College
Room 200—'
IV
lanning/Zoning p� r _ J _� �. �► i/
N. 721 Jefferson l�
Engineers
N. 811 Jefferson
❑
Utilities
N. 811 Jefferson
❑
Plan Review/ Fire Prevention
N. 811 Jefferson
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Other (SEPA/Critical Material/ate.)
❑
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 age compile said application is true and correct.
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