1986, 07-23 Permit App: 00012264 Foundation(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 orlginai and your building plans to the Department of Building and Safety)
_
Protect Number -
Owner's Name LAST sr!
Gi
GX'owf i b/r/'_
Project Address (Street Name S. Number) Zip
S. 8/3 &ij,4 922/6
Applicant I Address
L
City
Stale
Ziu
Phone
( )
Business Phone
I 1
Contractor/Agent /—GS / 1 i
C/ /o%%`
Con rfroie'f/-oh d0 ,
Ad.❑ass
- P0 box /jCieo C
CityState
5`p6k4h2' ,
7 p
/4. X31/ L,92A
Phone
(5°1) 925- 6Jfyf
Contact I
I A ry c e 1
,-
License Number l Requuudl
F_hLLbxc/ '. e
Busines`. Phone
( (e I t,
Architect/Engineer
:!
Address
City :
State.- _ '_ - -+I Zip
Pnone
Contact -
Business Phone
( )
Lender
1
Address
City `
State
Zip
Phone ( I
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Zone
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Census Tract
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Lot Size (Sp. Ft./Acre) i
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G`rou- P
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 to compile said application is true and correct.
Signature
a/104 2/.147t
Date
Approv
Cond.
Approval
Hold
Environmental Health Application #
d
if .7 C7i / Y
-IA"
7 13
0Room
W.1101 College
200
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Planning/Zoning
N. 721 Jefferson
1
I4
Engineers
N. 811 Jefferson
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Utilities
N. 811 Jefferson -
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- --'- ---- -- - -_ ---
,
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/ate.)
NI r\
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
a/104 2/.147t
Date
••••••a0 CM+
Show on Site Plan:
Additional information:
Lot Dimensions
Existing Structures
Proposed Improvements
Stricture Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s) . .
Right of Way Width(s).,
names of : '-• . \...
Fronting Street
Flanking. Street
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
. Signage
Shorelines
Highwater Mark
.
Legal Description
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