1986, 05-19 Permit App: 00011173 Residence (THIS IS NOT A f ERI IT) 5/( SO
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 ProJectNumber / /, "1
Owner's Name LAST FIRST MI / r
Lt)olF/4'J01 ea
Zip
Project Address(Street Name&Number) /
E. / / 3 / ( 4f
4a e-%
I Address
L ,e0/,e0/Applicant Sr 2/ .7 i)/Li)c/�/�;�d Vin- s
State // I Zip �f Phone j�
City /� /1 W It V!a oC `i/L'9) 90(/ --��9�
�r( „ Business Phone
( )
Contractor/Agent I Address
b)D/r f7-,Js 000. s. 7/ 7 .t/e_s i-.
City State Zip Phone
✓
- -' one
Contact 11f License Number(Required) Business Ph
p9
Architect/Engineer Address
/ �� / Phone
St Zip
City ( )
Business Phone
Contact ( )
Address
Lender
City [ tate Zip Phone ( )
Res. Comm.
Describe Work
Subdivision/Plat Name/Short Plat Number j
41-...... . h ,o . hi a' /r' , '.fit i1// / /i.c'"
Assessor Parcel Number Lot Block Plat Number
/L /
Census Tract
Pertinent File Numbers Zones. ^ Comp.Plan
Number of Dyrelling Units INumber of Buildings
Lot Size(Sq.Ft./Acre) Depth I + Frontage t
Front Setback ‘
Left Setback Right Setback i Rear Setback R/W Width
7 � ..5b t
�.i ( Square Footage
Additional Information j�q.�
i MF
Z 7111 "- Z.1=
0 _
0 528 = aA
u.
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0
CO Number of Bedrooms
.BGroup Type
.Building Technician Date %_ j �l,C /pj/ r �.
DEPARTMENTAL REVIEW •
Cond.
Approved Approval Hold
Environmental Health Application# e--43/514. W.1101 College
Room 200
4441
Planning/Zoning
❑ N.721 Jefferson
44 go
Engineers '7/4- /Y7
N.811 Jefferson `
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention y"-fid
❑ N.811 Jefferson f'
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, ,�. a./ �V fl'Glf Date 77�e �'
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