1982, 09-28 Permit App Worksheet 82A-8791 Garagej o3�
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
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( 1
(m) Department the Only
1 Owner's Name q
Pias.
Comm
2 Protect Addreef not Mailing Address) or Road Name
Space
Zip
�j
State Subdivision/Plat
Name YY) I
fLLi�
3 City/Community
5 1
S�saaaas
4 plessor RetoolNo.
Lot Block
+ + + DEPARTMENT
USE ONLY + + +
191 59 I — o
5 Sic Cade
Zone S0�Prolmt No. Z16
iA1J�
Dwell M
Building
Sq. Ft.I Acre
Depth I s.40
Front�er7
#Act.#
Sat Bade -Front
(R)S-2
Rear
Census Tract
Module No.
Initials
O m .
+
16 Architect Firm Name
Street Address
Zip
City
State
Phone
1 )
Contact PersonPhone
If different than above
Contractor Firm Name
Street Address
Zip
City
State
Phone
1 I
Contact Person
License No.
Phone If different than above
B Owner/Agent (it different than #1 above)
Business Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (YIN)
Other (YIN) SEPA
Exempt (YIN)
Date
15 Type Work [IBldg
fd. MN
❑ New
7 Replace
El Other
I❑ Fire
❑ Demo
-1 Addl Alter
❑ Move
14 Describe Work I
0 1
10 Applicant Nam
�f �C C7
Street Addr s
c
11 Zip q/ 2—
�l � L
City
State
� Q
Phone
(�b )
Lender
Street Address
Zip
City
State
Phone
I
Contact Person
Phone if different than above
IMPOSE
Additional Information r ^& �7r- _ ,-, I �
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70'
aaivswAY
DFSMET AVE
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Mpo sen
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3 BED Room
M9BIALE HOME
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