1986, 10-29 Permit App 00013891 MH(THIS IS NOTA PERMIT)
BUILDING PERMIT ARRLIGA4 IDN WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS Or i HE 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 1 386i
Owner's Name LAST
`C r Ct"
FIRST ` MI
Project Address (Street Name & Number)
Zip
S22
1�2
Applicant
Address
City
State
Zip
Phone
Business Phone
Contractor/ Agent
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
Describe Work
70/
Res.
Comm.
`� i C� ,LE W tc� '�
1
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Subdivision/Plat Name/Short Plat Number
L-W,"ca L -M Moat `� �sa2�c
Assessor Parcel Number
Lot
Block
Plat Number
- Z Zj e>Z
Z
..
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
9 >m 1-N
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
LIS xLs-1-I N) JF>lr -rC--r- s
Additional Information
Square Footage
Z
O
H
Q
O
U -
Z_
O
Z_
M
Number of Bedrooms
Building Toch nipk�`
/� �/�
Group
T
�8.
Z -V 4
Uh�
0
C
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r
r
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application# 2�
W. 1101 College /
Room 200 fb .
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities CI N.811 Jefferson I
r
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.
Signature \Date___