1985, 07-24 Permit App 00006529 Pool(THIS IS NOT A 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 L./St
I Project Number
Owner's Name LAST FIRST MI
F� L C.g 1 G G e,;c_14__ 1e-(3
u
Project Address (Street Name & Number) Zip
E. to- 17— f., 4
Applicant _
Address
a . r 7 1-/G pm RAI
City
SG
State
�iti.—.-
Zip
/90/ (0
Phone
/ (re,) 9i2-9z /
Business Phone
( )
Contractor/Agent
akS4 P -
Address
l\
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/)
j, /11q ,nay %(J
City
State
Zip
7720 (o
Phone
( (SI) q2p.- S7 91
Contact
License Number (Required)
Business Phone
( )
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State I Zip
Phone
Describe Work
EY-v/u,u1AJ{2- Poo L
Res.'
Comm.
Subdivision/Plat Name/Short Plat Number
Ii;Lb-. F1rrApe)
Assessor Parcel Number
Lot
Block
27
Plat Number
Pertinent File Numbers
Zone (1fR'
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
277.91
Frontage
i15)
Front Setback
Left Setback
Right Setback
Rear Setback
Additional Information
. DEPARTMENT USE
Square Footage
Group Type
-wilding Technician Date
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Health Permit Number
Environmental
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
I
N. 811 Jefferson
Plan Review/Fire Prevention
N.811 Jefferson
Other (SEPA/ Critical Material/etc.)
j 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 is true, correct, legal, and binding.
Owner's Signature
Date
otA
4 Svc> p
Ite)-1-40:31
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