DYER N 409 VALLEY YAMAHA SIGN
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~ (THIS IS NOT A PERMIT)
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- BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOD 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 LAST FIRST MI
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Project Adoress (S ree~ Nu m 'J
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Applicant ~ Address .
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A Li CNy State ~ Zip Phone
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Business Phone
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Contractor/Agent Address
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City ~ Statet ~ ✓ Phone
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0(0ontact License Number (Required)' Business Phone
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ArchitectlEngineer Address
City ~ State Zip Phone
Contect Business Phone
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l.endor ~ 1J ;Address
Gly ~d Siate 2fp Phone
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Oescribe Work es. . ~ Comm. . .
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S~vlsfon/Pta! Name/ rt Plet Number
Assessor Parosl Number Lot Block Plet Number .
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Pertinent File Numbero - , Zo4r Census Trec!
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Number ot Owelling Unfia Number af Buftdlnpa _ Lot Size (5q. Ft.lAcre) Oeptn Fronta9e
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Front SetDeck Le}t Setbaclt _ Rlght SetbaGc Rear Setback . RJ W Width - ~
Additlonal Informetfon . . , Square Footage
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DEPARTMENTAL REVIEW .
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Approved Cond. Approval Hold
Envlronmental Health Applicatton #
❑ W. 1101 College
Room 200
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Planning/ZoMng
❑ N. 721 Jefferson -
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Englneers
❑ N. 811 Jefferson be UoC-iateC.k Oufi ~ j c( t.
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utilitlea
❑ N. 811 Jefferson
Plen Ravlew/Fire Preventlon
❑ N. 811 Jetferson
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Other (SEPA/Critlcaf Meteriel/etc.)
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~ Faat Treck/Speclet Inapectlon Intormation - ~
Pro)ect Representative Phone
Address
I certify that f have examined this appllcation and state that the intormation contained in 1t and submitted
by me or my agent to compile said applicatlon is true and correct.
Signature . Date