1986, 01-02 Permit App 00009453 Cover, Deck(THIS IS NOTA PERMIT)
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)
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Project Number c L
Owner's am LAST
FIRST MI J
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Project Addre Street Name & Number
2ip . ffdr,
Appl ica
Addr
N 5 4JL
City
St
Zip
Ira?
Phone
_509 ( aSZ5Z5T
Business Phone
Contractor! nt 61-2rOdr./21.)
Address
City
Staf eb1 v
'G/ �
Zip
Phone
( )
tact
License Number (Required)
Business Phone
( )
Architect n ineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
I Zip
Phone
Describe Work r
,_ -.- HOe1LE CIO VLF(tr 4i)Evie/_.6SSFo cc-
Res, /
Comm.
Subdivision/plat NamelShort Plat Number
Assessor Parcel Number--
Lot
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Front Setback
Left Setback
Right Setback
Rear Setback
R/ W Width
Additional Information
BUILDING INFORMATION
Square Footage
Number of Bedrooms
Building Technician
t-.
C/i/"' .r
Date
l — , i)
Group
1sr-8
Type
rlA)
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
I
I
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
e ify that I exam' - ed this application and state that the information contained in it and submitted
by or my a_ - c • e said application is true and correct.
Date