1985, 09-04 Permit App: 00007574 Residence(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK 06
57
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(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Owner's Name LAST FIRST MI
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IProject Number
Project Address (Street Name & Number)
Zip
Applicant
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Address
City
State
Zip
Phone
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Business Phone
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Contractor/Agent
City
State
Zip
Address
Phone
Contact
License Number (Required)
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Business Phone
Architect /Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
y dee . i
/ eS
I Zip
Phone
Humber of Buildings
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
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Approved
Cond.
Approval Hold
Environmental Health Permit Number (— 707
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W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
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Permit Number
Engineers.1f f/VA- �
N. 811 Jefferson
Utilities
N. 811 Jefferson
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Plan Review/Fire Prevention risfp,,
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
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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
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Show on8doRon: Additional Information:
Lot Dimensions Landscaping
Existing Structures DrainagePlan
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Proposed Improvements Hydrants
Structure Setbacks Topography
Easements Lighting
Septic System(s) Signage
Water Lines Shorelines
Sewer Lines HighwoteryNork
Fence .VVoh
Driveway(s)
Hight of WayV0dthhQ
Names of
Fronting Street
Flanking Street
Legal Description
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Doale:
Date:
Revisions: Attachments: