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1986, 03-04 Permit App: 00010015 Residence(THIS IS NOTAPERMIT) 3(Z" %' 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 I Project Number (00` Owner's Name LAST FIRST MI rel! . <C J 9r ors- 0C- . /..e/C. Project Address (Street Name & Number) Zip i5 S) a J e .)S ,2.0. L*-E . . rOK•rx,E ei- -' 91-464 Applicant ck Address City State Zip Phone ( ) Business Phone ( ) Contractor /Agent C(, r S ck 05. CC - //tic--- Address /e• 06ex" ! roes, City 01("1/ State u' �' Zip P,I Phone ( ) 9) l _ 0 le 2— Contact g14 C gsri! i'n License Number (Required) 11,4 S As'S 4J_ , 6 Business Phone ( ) Architect/Engineer Address City State Zip Phone ( ) Contact Business Phone ( ) Lender Address City State I Zip Phone Descrtbe Work S alt e E Fie4ti .feArzorp..ceE lit Drl4 r Res. Caron. Subdivision /-Plat Name/$hort PlatNumber t ,. !!/� Assessor Parcel Number Z7umbT / "'� QC? Pr_)) LotLot Block Plat Number Pertinent File Numbers Zone Comp. Plan Census Tract Number of Dwelling Units / Numberof Buildings / Lot Size (Sq. Ft./Acre) Depth i,c/ A Frontage Front Setback P34'. Lett Setback Right Setback Rear Setback r v R/W Width Additional Information Square Footage n(,f. 4 CI73 li Z(j=el9fi 0 r 473 cc 0 u. z 0 z 0 J CO Number of-Bedrooms Building Technician Ciyz[j1) Date 03-©�- owl, *4 fi.21 Group 12-3 Type v1 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. Signature Date YeVe‘ Approved CpApproval Hold Environmental Health Application # o n e... / 6'7�i / // .=. • Cif i` ' W. 1101 College Room 200 Planning/Zoning N. 721 Jefferson Engineers N. 811 Jefferson # ,, 3/ y Utilities N. 811 Jefferson I 1 (gf- rat Prevention Plan Jefferson 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 to compile said application is true and correct. Signature Date YeVe‘ Show on Site Plan: Additional Information: Lot Dimensions Existing Structures Proposed Improvements Structure Setbacks Easements Septic System (s) Water Lines Sewer Lines Fences, Wells D riveway(s) Right of Way Width(s) Names of Fronting Street Flanking Street Landscaping Drainage Pian Hydrants Topography Lighting Signage Shorelines Highwater Mark Legal Description Legal Description J'' / /jcpc ,K / /File" E!O/Fri/ Ssr— ": /r -,q 4/ f