1986, 04-18 Permit App: 00011181 Residence(THIS ISN -OT A PERMIT) 4410
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
Owner's Name
do.
LAST
FIRST
MI
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Pro ec Address (Street Name & Number)
Zip
E o 2 —
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Applicant
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Address
S. 717
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City ��
O`r
State Q !
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Zip ��4
Phone (� �)
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Business Phone
Contractor/ Agent
Address
City
State
Zip
Phone
Contact
e
License Number (Required)
,446 ZA'X
4
Business Phone
Architect/ Eng i neer
Address
4�/—h�A
City
--------7
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
phone
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Res.
\7
Comm.
PW,`
/Short Plat Number-
/J2
,er
Lot
Block
Plat Number
/
Gn+`�
inent File Numbers
Zone _
Comp. Plan
Census Tract
tuber of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./ Acre)
Depth
Frontage
Setback
Left Setback /
Right Setback
Rear Setbggk
R/ W Wid In
itlonal Information
Square Footage
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Number of Bedrooms
dingTechnlcian
Date
Group
Type
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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.
Gva yll�>�' �O•
Signature Date
v �.J
Approved
Cond.Approval
Approval
Hold
Environmental Health Application N
W. 1101 College
Room 200
/Planning /Zoning
N. 721 Jefferson
-.11A
7140
Engineers
N. 811 Jefferson
' `/
,.. O�
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
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.
Gva yll�>�' �O•
Signature Date
,V"' p ✓.C. D-3o3Y SofZ�S
SGo Pt-, Cr9PPED EN DS,
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