1985, 08-26 Permit App: 00007225 Residence(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)
s7r11.11-Iw rnCno riinrvn v�rrrn 1 rviul 1 r%L vac
1 ` I „ 5
Project Number 7l�l
Owner's Name LAST FIRST MI
C// 4- 4'' rf S S c c .-,f -TF S' %4V
Project Address (Street Name & Number) Zip
/3 7 c 7 E .L /7-1.4: C'�'c,,,- 7— .,e 'irifX47 jQGc5
Applicant
it), 4 r rts-s c> c //I-77 i /X ic=
Address
, el • /s,/ x /Yom/
City
Vic'«� f
State
a,z,,PL
Zip
, Y
Phone
( ) -,1-. fes,- 6 5d/
Business Phone
( )l- - d7eij2--
Contractor/Agent
.c "1 Ci
Address
re' /,k !yG(3-,/
City , _
S>e,Kklic t_
State
C[ %.
Zip
22---- r t/
Phone
( ) 9;-Y- C„ pe,1
Contact
it. /Ain/
License Number (Required)
V LCASAs - „v_`fJ MG
Business Phone
( ) -2 - 07J -2 --
Architect/ Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
( )
Yhnk �+
He
Gt xt.
P
aftt
P. Hatt ,
7 ,
tie
l) • Rt LAflre} :. " 7
{t.
DEpARTM
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 is true, correct, legal, and binding.
Owner's Signature Date
Approved
Cond.
Approval
Hold
�/
Environmental Health Permit Number O
7D
I kJ
_ Hs i�
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Permit Number
4 1
Engineers
N. 811 Jefferson %rN/¢.<-4/ri
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
4&C't
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 is true, correct, legal, and binding.
Owner's Signature Date
Show on Site Plan:
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
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Scale. �V- S
Date:
Revisions.
4,/
Attachments:
Legal Description
JO C T 7 ,61oc t (
/-. X, "7e -if j/e its -C1
r
/ J12
t
Scale. �V- S
Date:
Revisions.
4,/
Attachments:
//L / 7-1--
// / \(L-
// / (2