1985, 10-07 Permit App: 00008185 Residence (THIS IS NOTA PERMIT) �2 ��1
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 I
Owner's Name LAST FIRST MI
Project Address(Street N e&Number) /V l�� Zip
/2.-
,
�. / Zoo Z 347 /G1
Appl' nt Address
Ze i/i- y /�,.t _ i L, z sro�� e��
Cit State Zip_ Phone
City
„•,c am yZ�� c ) 7Z� — '”6 6
Business Phone
( I
Contractor/Agent Address
-/ ire
City State Zip Phone
( )
License Number(Required)
Contact
6Business Phone
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
!]esiri#7B Work
1 .,
Subdivlaion/Fiat Naaiet8htu't PIat
y � A A -,..f,,-„,„ 8 "td i',”- C., Q
Assessor Parcel Number kat BlOCk Ptat 4umber
, 35 / ` A .
Pertinent File Numbers Zone Comp Phar trens4s;Tract
f r 4L Yr �, -
Number of Dwelling Units 1 r'of a(dings
U14-177--'"
t14$17(9t4,f fA 4'eptft
! "°x: ` � c;� ' Seth} :i rvuYtri Y
Front Setback Left be9tt
Additional Information yt rel tage
f u 6
of Bedrooms
Building Techniolan oat* g G°oup ' Type
DEPARTMENTAL REVIEW
Cond.
ApprovedApproval Hold
Environmental Health Application#
❑ o m 2 College 1-R6l T kIr A / PLA A�
Room 200 / �~'
Planning/Zoning
❑ N.721 Jefferson
pl..
�Engineers C' .
N.811 Jefferson / 'rA —6 4/0 /..A
Utilities I
0 N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
❑ ,c6c
❑ Fast Track/Special inspection Information
Project Representative Phone
Address
I certify that I have -xamined this application and state that the information contained in it and submitted
by me or my agent • ompi - aid application is true and correct.
ICP
—77
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