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1986, 05-22 Permit App: 00011204 Residence (THIS IS NOTA PERMIT) BUILDING PERMIT APPLICATION WORKSHEET I 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 Project Number II 17-(; (' Owner's Name LAST FIRST MI W1IfMA-AJd Geo. Project Address(Street Name&Number) Zip F. ii&6 (?- 41 - Cower' Applicant Address W©/J1A,I C o. 6. 7/7 Roves hi City State Zip Phone I ��pokQ,ig, tQ. 99d66 (a-f ) 9. -as'9.2. ! Business Phone ( ) !I Contractor/AgentAddress W o/Ai/4,0o1 a. Sa-me. _ City State Zip Phone ( ) Contact License Number(Required) Business Phone c v. Sepia uvcd.r Ac. i�y P7 ( ) Architect/Engineer I Add .TPk- SPA,`AL/ City I State Zip Phone [ I ( ) Contact Business Phone ( ) Lender Address City State Zip Phone ( ) ;;.ibe Work , Res: /. Comm. ` . ' r •6�,PCI. w. /�4P ✓ 4.ivision/Plat Name/Short Plat Number ��� , �'`DA)` i► e% r incael0uls a �--sorParcelNumber Lot Block Plat Number :: . .3s ..3 --** 57/ 11 I inent File Numbers, ZoneSr Comp.Plan Census Tract 'Scriber of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage I Left Setback Right Seek RearSetbabk, R/W Width :if.Tttona!Information Square Footage /33/ = A-IF z 133i = lire 1° O 2 am" o 1-76 = oEC.- �� z m Number of Bedrooms .Inc; echn'on Date Group Type ° t 3 \J` J DEPARTMENTAL REVIEW Approved CpApproval Hold Environmental Health Application# ❑ W.1101 College Room 200 • Planning/Zoning ❑ N.721 Jefferson c2z Engineers ❑ N.8111Jefferson Utilities ❑ N.811 Jefferson 5-2346Plan Review/Fire Prevention ❑ N.811 Jefferson Other(SEPA/Critical Material/etc.) ❑ Fast Track/Special Inspection Information Project Representative I 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 cgnpil s id applicaticya is true an correct. Signature40/1/44/.> Date • '..„ o ' e. yy F/O1 ' I I- \1 7,-----„,..„„„„:„.....,e,, , O � y Q I ,, • / 4171 � �' li 1} y 0, i 1. h / �t 1. '; . < if .3.),,,, , 7-"V` r t 44 f; "N ii7 . ,-, A it q ie. 0C� ti. may. Nfty .J ley y- /y 1V`' y LOT /4, to Z, -37 ---i• , ,� • Fa.04S7--ArA.�ows 0 .C'17 s `\