1986, 11-03 Permit App: 00013995 Garage (THIS IS NOTA PERMIT)
BUILDING PERtir'T 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 i 9 5 ;,;, ,,,::
Owner's Name LAST FIRST NAI !
Project Address(Street Name&Number) ZIP
Applicant // 34Address
;'
City State Zip Phone �h
( )
Business Phone
( )
Contractor/Agent Address
!Y,, Co a s � C-'
�"l l3 3 3 Lilly �, t(/E,
City State Zip Phone (2 at) C / 75s'
yrs ���,� �fe 9 31s
Contact License Number(Required) Business Phone
PM oV /3 1Jb ( )
Architect/Engineer Q/�19� Address
City State �/ Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
s Res. 6,„,..." Comm,
' ' i,4Tc'l '�II [o
rd �
sorPaNumber Lot Block Plat Number
Pertinent File Numbers
zone
Comp.Plan Census Tract
iZ
Number t i)ttg Units ; Number of Bu dings Lot Size(Sq.Ft./Acre) Depth Frontage
•
, t Se , ' 4,42 tit-
Left Setback,_ Right Setback Rear Setback R/W Width-
ftdditional infomnatictn Square Footage
50 P
ce
h
U.
2
m Number of Bedrooms
Group Type
gg
Building_Te�fliP(an ,�: - Date 1 'eIQ
ar
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application#
❑ W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
7
Other(SEPA/Critical Material/etc.)
❑ y
1
❑ 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
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