1986, 08-01 Permit App: 00012437 AdditionDEPARTMENTAL REVIEW
Environmental Health
W. 1101 College
Room 200
Application # l 67
Approved
Cond.
Approval
Hold
Planning /Zoning
N. 721 Jefferson
I 1 1
Engineers
❑ N. 811 Jefferson
Utilities
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 compile said application is true and correct.
Signature Date
(THIS IS NOiA PERMIT)
BUILDING PERMITAPPLIOATION 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)
-- .._.._ ...._ . —.. — „. , , , —.. , ,.",,,—
Project Number /L. 3
Owner's Name LAST
-r L e -
FIRST MI
Project Address (Street Name & Number)
S 91/ ,� Abv IE'/ vek .a4-i e
./
Zip
h'4 . r9a 57
Applicant
4 \/ /� f
Address
City
State
Zip
___,514/%1
Phone
50? > 9...? -.84,/:
Business Phone
( )
Contractor/Agent
Address
City
State
1 Zip
Phone 1
( )
Contact ' '
License Number (Required)
Business Phone
( )
Architect/ Engineer
Address
City
State
Zip
Phone
( 1
Contact
Business Phone
( )
Lender
V45/F/A/67—,ici 77J/5 % 6/(-1--
Address
/4/ / /.3/7 -Y C
City
State/ )) /�
Zip /
Phone
Describe Work �,,
61 f'�20, GA E e t )
i TC }' �N
Res. /
Comm.
Subdivision/ Plat Name /Short Plat Number
t 0 i7t0iV
Assessor Parcel Number
Lot
\ t
Block
Plat Number
Pertinent File Numbers
.tone
Comp. Plan
Census Tract
Number of Dwelling Units
.
Number of Buildings
Lot Size (Sq. Ft. /Acre)
Depth
Frontage
7G
Front Setback
Left Setback
Right Setback
Rear Setback
R/W Width
Additional Information
1 BUILDING INFORMATION
Square Footage
/OS S
580 C41'
Number of Bedrooms
Building Technician
Date
Group
Type
Show on Site Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
2
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tkes.ISE
140
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