1986, 06-13 Permit App: 00012221 Garage(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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number
/._..22 f
Owner's Name LAST FIRST MI
CjktcktLL L- .
Project Address (Street Name & Number) . Zip
1 ' 3 M. I c i c s k a. i1�, (i� i)
Applicant
Address
City
State
Zip
Phone
( )
Business Phone
( )
Contractor/Agent
L. I'Y,o (25 a--CEL, cc tit.6,% )NC
Add ess
e 300q GPI--P-UA-&3(
City
po Ka_ nia.
State
UJ as k
Zip
q q oo--7
Phone
569) qS3- (-)S-rS
Contact
Li ense Number (Required)
.rs -hri5 B -15Q mJ
Business Phone
( )
Architect /Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State I Zip
Phone
(
i)escribe Work -
. G-A-RAG- Lt g x .3(:,
Res. /
Comm.
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number
i6' 51/3 — t.)5-i/S
Lot
2—
{
Block
/52—
plat Number
Pertinent File Numbers Zone
I
1 Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
3096
Depth P
300
Frontage2-
/On
,t Setback
Left Setback
Right Setback
Rear Setback
R/ W Width
Additional Information -
BUILDING INE6RMATION
Square Footage
i 728 r
Number of Bedrooms
°..G
-Group-
N
DEPARTMENTAL REVIEW
Approved
1�
Cond.
Approval
Hold
i
Environmental Health A'pp kation M
i�Room
1101 College /� ait''G`
200 f%
�4 0Room
•
Planning/Zoning
N. 721 Jefferson
•
Engineers
N. 811 Jefferson
•
Utilities
N. 811 Jefferson
I
•
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 t compile said application is true and correct.
Signature
Date
'74 a /1r67
Legal Description
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Scale:
Date:
Revisions:
Attachments:
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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
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Scale:
Date:
Revisions:
Attachments:
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