1986, 05-19 Permit App: 00011129 MH(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMP! ETE 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 USE
Project Number
Owner's Name LAST FIRST MI
71.
Project Address (Street Name & Number) Zip
N . 31D oL,\ 1/412- Q1D .
1_
Applicant /
7
Address
City
State
Zip %
1
Phone
T
Business Phone '5.3<9
_ 16X -
5.y
Contractor /Agent
Address
7��►<-�'l
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
l
Desa ibe Wok
bi1OF-- rude 2g $7O`
Res.
Comm.
Pl
Sutxiiyisianf /aNumber at N ipeShort Plat
_ :,.317 -ft15 r/
Assessor Parcel Number , .
43:;_ a0.&I'j C.e0KOKi)
Lot
Block
Plat Number
t
.-.,e e - 397 C
Pertineet File Numbers r:.
Zones c , 0 f
Comp. Plan
Census Tract
Nt •
ijng t)nits , rr
Number of Buildings
Lot Si e (Sq. Ft./ Acre
Depth `
Frontage
1
� ett►adc b } ` .,
Left Setback t
Nt iN _
Right Setb ck
S /
Rear Setback /
•• 07/7/ 21.
R/ W Width
Sa
Additional Information
Square Footage
Z
o
oC
o
U.
CS
Z
go-ik' eEi
9 r -
m
Number of Bedrooms
IdinoTechnl an
Date G]
/ g63
Group
Type
-
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 (d_ fz ` l mf.,( Date
Approved
Cond.
Approval
Hold
Environmental Health Application # r - -1-"Z__/j/
5719- fins
//
W. 1101 Col lege
doom 200
Planning/Zoning
N. 721 Jefferson
, /
0
S"S v• /i
S- '717qc r 5.11
p g 3� 7 l ,3 4ei_
L& S7s o 5 7 C '� �5 /I0 7 e--(
Engineers // !��/ n '/� -,-
Engineers
N. 811 Jefferson 7�i,1G(• o� Jr
Allliddr
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 (d_ fz ` l mf.,( Date
a4L4p, P vt- &‘--
P45TM D-7634 SPZ3f
Asrm F7a5 4ta'A•44L.
eme4.t.
;444 cipm..44.
Y.3
I
wol
t 4
q)1'
V,J
'‘b
•
_
'j .1%
••
••••
n •
)-
I ,
...._ 4 ,
O0:1r
c\
I ec,t (,.fi- ixa-i' 0j2,4 ?& i :47
- .
<- Pkie •-,'- '
Legal Description
r -
t
r
Show on Site Plan:
Additional Information:
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
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
r -
t
r