1986, 05-20 Permit App: 00011516 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)
SHADED AREAS ARE FOR nFPAnTnt1FNTA1 I ICFi.r_►_.
Project Number
Owner's Name
LAST
FIRST
MI
/tJ C
Project Address (Street Nam & um r)
-- Zip
Applicant
Address
City
Stat
Zip
,,l - U
Phone
Business Phone
Contractor/ Agent
-j {
Address
City
State
Zip
Phone
(
)
Contact
License Number (Required)
Business Phone
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
nosiness Phone
l
v
Lender
-- - -
Address
tatty
State
Zip
Phone
{ )
Describe Work
�lf
Res.
comm.
Subdivision/Plat Name/Short Plat Number
—
Assessor Parcel Numbor
Lot
Block,t
Plat Number
Pertinent File Numbers
Zon
Comp. Plan
Census Tract
Number of Dwelling Units Number of Buildings
Lot Size (Sq. Ft./ Acre)
Depth
Front e
t
��
Front Setback Left Setback
c
Right Setback
1
Rear Setback
R/WWidth
70 t
Additional Information
Square Footage
ff0
y
0
ILL
Z_
a
z
0
J_
M
Number of Bedrooms
Building Technician Date
i.
Group Type
t.� -517
5
a
T
n
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
Approved
Cond_
Approval
Hold
Environmental Health Application M
W. 1101 College
Room 200
-7006
-�
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/ Fire Prevention
N. 811 Jefferson
2 t r7
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
IJ
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