1985, 07-22 Permit App: 00006597 Residence(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)
' JHAUCUAMtMb AMCFUMUtVHM1 MCN I HLUJC
I Project Number (_p s 1
Owner's Name LAST FIRST MII.
/949/.c., f/r.,stkir( S
Project Address (Street Name & Number) Zip
/</ c S 3/6 X£ s e - 9 9a7c
Applicant
F�tia "crs • �� y qn4-
Address .. .
C• /19;0 /Q,4,e,aap -cc
City
C PC) -
State
w!4
Zip
970100
Phone
(. -' 976'/&if y .. .
Business Phone
Contractor/Agent
HALTK/k/S ('ter
Si /Pe'cr1 aA-) GC's-
Address
F'
/ j 7 / - w sr
City
5/au-a-Air•
State Zip
Ci. i4 9'90LoC
Phone
( ) 9.2 z../a Y7
Contact
1 aOHL) ,46+ c ---/f
License Number (Required)
hWLftic 22c 31-C
Business Phone
( ) .s` ,i£
Architect/Engineer
r
Ate
rr c d
Address
ec,o
City
State
Zip
Phone
Contact -
Business Phone
Lender
Address
City
State
I Zip
Phone
Describe Work��TT
9l0rr_Y,'
Res.
Comm.
Subdivision/Plat Name/Short Plat Number
SWC AteUri 74 kOD ,
Assessor Parcel Number
3cc1; "
oI
Lot
)
Block
`z_
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Numberof Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth��,
Ilii Frontage
Front Setback
4Q I
Left Setback
7
:5
Rights back I
rJ
Rearesettbbac
//D t
Additional Information
DEPARTMENT USE
Square Footage {�
4
A31
IME = Gtr[.
Gam-: 672/
Building Technician
400 r ,
Date
7 h1 -0c
Group
r 3
Type ,•,
V «
DEPARTMENTAL REVIEW
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 G( -V Cy 0w- fr C
Approved
Cond. Approval
Hold
Environmental Health Permit Number
W. 1101 College
Room 200
//��
YJS -°13(0C
/�
I�,,.��
N . I
'� I
PrnNOMG Pfp2ouPsf. or
'T ffiatE
��� 14
Planning/Zoning
N. 721 Jefferson
Permit Number
lf-2Z-
/Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
7,23-S.
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 is true, correct, legal, and binding.
Owner's Signature
Date G( -V Cy 0w- fr C
'
Show on Site Plan: _
_- Additional Information:
Lot Dimensions
Landscaping
,
Existing Structures
Proposed Improvements
Drainage Plan
Hydrants
F
Structure Setbacks
Topography r
'r
I
1
Easements
Septic System (s)
Lighting
Signage
Water Lines
Sewer Lines
Shorelines
Highwater Mark
Fences, Wells
Driveway(s)K
Right of Way Width(s)
e)—�
•
Z
g
f
Names
�rti
{
of
Fronting Street
Flanking Street
6 rcr ,
L,
I
�
f IIf
Legal Description aq gc; r
rC413—ea.)i1, ir
I
/riT I &cck az
j
I
1 L
Sc 4 � 4-c le cS' �ra ti
(
40 nirI 0 4) A -f fr n/t0c
i
/.
/,I LiO('; /6 jiy ?7
1 4
j
j
rar:n.:T1-r
S Cts4,u6
j
'Jt7t
,4. S c±F, rcC
I
'
I
1
I
7
i 1 i
I
I
Ht
j
I
r
Scale.
J
Date:
!
1
Revisions. Attachments:
I I
I ---VAS
Ili*
VV4AL.2
✓v( 1, K2
7
2'
-P(.e'�cry
--- --
;mI )l
LAtcl
IiflAJIJC-
;r.
0
i
<< 7
;•;:
/1/5 3/6
4
3
19'
/_
•0
4"
•
�oo�o0
tJo>2
IL f