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1986, 06-30 Permit App: 00011902 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 OEPAR I Mtn I AL Usk t Owner's Name LAST f _ �! /FIRST MIR Project Address (Street Nae & Number) Zip / �? R P �g‘-), tk2� 3 Applicant LLEA/RE i. 6 R Address srlC� City S,y7: ( !� t�� State j Q 6i Zip "l c(-`. j t Phone (S-0(1)7)(' (�' C Business Phone ( ) Contractor (Agent Address City State Zip Phone Contact License Number (Required) Business Phone ( ) Architect/Engineer F Address City State Zip Phone ( ) Contact Business Phone Lender Add ess City State ( Zip ji Phone Describe WRes• c.) �� g cz vek e 3 o X 4© Comm. Subdivision/ Plat Name/Short Plat Number Assessor Parcel Number 125 31.— 0 et 6)� Lot Block Plat Number Pertinent File NumberZone) V �� LL Comp Plat Census Tract Number of Dwelling Units Number of Buildings Lot Size (Sq. Ft./Acre) Depth I t '3 3,9 — Frontage 89 Front Setback 5�)�TIIJCa Lett Setback Right Setbacki Rear Setback R/W Width Additional Information Square Footage z a P a i cc 0 1 z c5 z 0 -J m Number of Bedrooms Building Technician 1k; N of . DateGroup /��-� r-1 - Type DEPARTMENTAL REVIEW 1 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 Approved Cprov Approval Hold Environmental Health Application # /� �7 �/ / 2STJ / {� . o "VG , W. 1101 College Room 200 Planning/Zoning N. 721 Jefferson 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 1 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 Legal Description r t • 1 - t 4 I 1 t 4 17' : 4-. I • _ h &Vs—. )(I 1 --r- t r - ----r: f s '4" 7 ---t _MARK R.- SH9LLEABE.!: A6__It I.CV.1:17.4.6. • 1 - • I r • 4 rAt • -1- f >- 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 ik Legal Description r t • 1 - t 4 I 1 t 4 17' : 4-. I • _ h &Vs—. )(I 1 --r- t r - ----r: f s '4" 7 ---t _MARK R.- SH9LLEABE.!: A6__It I.CV.1:17.4.6. • 1 - • I r • 4 rAt • -1- f >-