1987, 03-25 Permit App 87000372 Residence4
(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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
( Project Number C7,7 _-'!77
Owner's Name LAST
FIRST
M I
,� / s
Project Address (Street Name & Number)
Zip
Applicant
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Address
S�/� D c �lhrnc�r� yam,
City -State
���Ca ��
&,J,4I?9jo
Zip
Phone
d� 1 9d2
Business Phone
( 1
Contractor/ Agent
Address
MC A61tz �e c�
/`i , 3 / Lo ro �� k�:( .
City
J� v
State
WA
Zip
Phone
(,t5o,J)
Contact \ C�License
y
Number (Required)
/j'1 C i/A Y13� 3 �� m�
Business Phone
( �n e
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
( 1
Describe W✓o
�y-r
Res.
Comm.
Subdivision! Plat Name/Short Plat Number '
Assessor Parcel Number
Lot
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Bui dings
.of Size 'Sy.Ft.lAcre)
Depth
Frontage
. s LL I
..
Front Setback
Left Setback
Right Setback
Rear Setback
R/ W Width
Additional Information { ;
Square Footage
/ j9'
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4
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0
W
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In
Number of Bedrooms
Building Technician
Date
Group
Type
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Fol
a
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DEPARTMENTAL REVIEW
Cond.
Approved Approval `told
Environmental Health Application N
W. 1101 College
Room 200 —
Planning/Zoning
N. 721 Jefferson _
Engineers
N. 811 Jefferson
UtilitiesL T
N. 811 Jefferson _
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 cornpile said application is true and correct.
Signature Date