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1985, 10-18 Permit App: 00008180 Addition
(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 V, ..,— Owner's Name LAST FIRST MI M C'CAN0(.�s K Art+Y Project Address (Street Name & Number) Zip a 15cf2Q 6 Romp , P o i W A. , 9' n% C. Applicant IJ ‘S M 82044Jd Address v- Iboo4 $itc•,e c) City 5Pb1 t State vNik-frog Zip q/sIC. Phone (say) 927 off)( Business Phone ( ) Contractor/Agent CIO OM. Address City State Zip Phone ( ) Contact License Number (Required) Business Phone ( ) Architect/Engineer Address City A2014 e. State Wd. Zip I ` i 2-L( Phone (5)) 921 o IV - Contact Contact Business Phone i ( ) Lender Address City State I Zip Phone Describe Work AQ tTloN TO t ��si nM►t,. : Rea Comm. Subdivision/Plat Name/Short Plat Number W tS cd..escax %{ 44 p►rvo R. l,.:4' 0 q©o Assessor Parcel Number Lot Block PI Number Pertinent File Numbers Zone tC 12. Comp. Plan Census Tract Number of Dwelling Unite Number of Buildings Lot Size (Sq. Ft. /Acre) Depth lzs Frontage aCOP ' Front Setback Left Setback ( i./4 Right Setback Rear Setback RAN Wiidt© -••+ on Additional Information FORMATION Square Footage 0 z 5 m Number of Bedrooms ' B9Tinare4,1 1 Date i )86^ Group T 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. Date X �2 /CJ er 0 Approvaond. l C Hold Environmental Health Application # W. 1101 College Room 200 i / AlbV� 4 . iq) �� Planning/Zoning N. 721 Jefferson Engineers N. 811 Jefferson Utilities N. 811 Jefferson I /Plan Review/Fire Prevention N. 811 Jefferson 'Ci4 -17)------- 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. Date X �2 /CJ er • Show on Site Pian: Lot Dimensions Exis roposed 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 Additional Information: Landscaping Hydrants Topography Lighting Signage Shorelines Highwater Mark a Legal Description a- T • TFFMf Ft? ti 1 1` caa -I --- -O R l .u� ltri t -4--i I e.4i i 17--(1 7- 0 lm40C., z -a r-14. . - - -- i iE if m! �n iicibt►i Off • .) --b 1 1- !______v__ 8`3 4iZ v , - -- --- j-- - broad Scale: Date: Revisions. i If __ - - -- -' I 4 - Attachments: