1986, 10-06 Permit App: 00013487 Garage ,.r
BC _--
(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 DEPARTMENTAL USE
Project Number /310/43 7
Owner's Name LAST FIRST MI
-{-h. oi' as at-e))a
Project Address(Street Name&Number) P Zip
(3006- E. 3
Applicant Address
City State I Zip Phone
I ( )
Business Phone
( 1
Contractor/ nt Address
c. pCity State Zip Phone
Contact .. qqii>
License Number(Required) Business Phone
one
SPdc A& I tg . ( ) > >
Architect/Engineer Address
City State I Zip Phone
( )
Contact Business Phone
Lender Address
City State Zip Phone
( )
I
Describe Work Res. jComm.
!Y t v
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number Lot Block Plat Number
Pertinent File Numbers Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
ZSi
1 C
Front Setback Left Setback Right Setback Rear Setback i R/W Width
7
Additional Information Square Footage
72.0 ,
Z
0
I-
4
2
cc
O
• is.
z
o
z
6
J
5
m Number of Bedrooms
Building Technician Date GroupType
ype
4' i
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application N
❑ W. 1101 College
Room 200 -kE4TM♦=�1T 1"L,4iLJ 1
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
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 Date
l ,
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i 3hos E, 3 i
POKANPc,-.6/..42 4 ''Z7sY - (7og -_ _
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