1985, 07-30 Permit App 00006616 ResideBUILDING 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)
1 Owner's Name ((/7(llaast)) (first) Department Use/O�{y
/�%
(/(177X �-is / �� -AL V-d f f—/
II
1Ras. ✓
Comm
2 Project Address t Mailing Address) a Road Name Space !!
Zip
T / )& / 7 /c>'A" alC!/— 99;0 6
3 aty/Commugity
oM_ -P,
Stat
Subdivisi /Plat Name
PP__T /N,- Y e / 33
4 Assessor 1 No.
r 1,5, /1 - /3 f5
7
Lot
1 Block
* * * DEPARTMENT USE ONLY * * ,r
5 Sic Code
Zone Act. #
Zone L r� ,
•
Project No. /� r� 9
Quell/ /6
6 Dwell #
No. of Buildings
Sq.Ft./Acre TT1 Depth
Frontage
7 Set Back -Front
(L)S-1
I
(R)S-2
I Rear
Census Tract IModule No.
Initials
k 16 Architect Firm Name
I Street Address
ll
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
6/7-/ro
Street
Address
ZIP q C' ` .
City,5ool a o e-
I State
Phone `� _/ ) Q2- 7 & r ,
Copt Person
j aK,-/- h e..- a/�
License No.
s_ l4V-L/4-1/I
&*(0 06
Phone If different than above
(509 ) af.-- 476,f�
8 Owner/Agent (if different than #1 above)
Business
Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan
Check (Y/N)
Other (YIN)
I SEPA
Exempt
(YIN)
Date
15 Type Work ❑
0
Bldg
Fire
❑ MH
0 Demo
0 New
❑ Add/Alter
❑ Replace
❑ Move
0 Other
I lr
14 Describe Work �i:_e_L.�
(/(/ 5 ,v'�
S! _ /f v �yf �/C
� ��/��
10 Applicant Name
U �
Street
Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
lua 76 .' 1 ,25-6 i./, c Q
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