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1986, 03-04 Permit App: 00010040 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) SHADED AREAS ARE FOR DEPARTMENTAL USE IProject Number 00/0 Owner's Name LAST FIRST MI , nc . S t,% A csottoirr f ,' 'c Project Address (Street Name & Number' Applicant City Address Zip jleiti-e, -6 State Zip Phone Contractor/Agent LO S V frt f gpc City Contac State Business Phone ) CRR - a zd' 2= ZiPt1<j Ann Address Phone ;i-/fhcoZ'C Architect/Engineer City License Number (Required) Lek,s. A S - .2�/J-i16r Business Phone Contact Lender City State Address Zip Phone Business Phone State Address Describe Work Z.'/W/4 E i6 »*lt A0es/ APWAiot. • Subdivision/Plat Name/Short Plat Number 7i Ade Arc F 1/,14 t2 isr-Ar7s-e` Assessor Parcel Number 2751 1 — 9 ooh Cfrr,. aN Pertinent File Numbers Zip Lot I Phone Block Plat Number Number of Dwelling Unita Number of Buildings Front Settack _ t Left Setts* 1failliO3.1116 It Information Comp. Plan Census Tract 4p 1 lot Size (Sq. Ft./Acro) Depth Right Setback IRear Setback 304 I.l �� Frontage 7 R/WZ Building Technician �1UIQ yr BUILDING INFORMATION Square Footage MF 86l Z�=784 6/4 Number of Bedrooms Group a--3 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 Approved Approval Hold Environmental Health Application # 1101 College Room 200 ---t7/ 1:6 5.2W. �� Ni�c-frt ��yam Planning/Zoning N. 721 Jefferson Engineers N. 811 Jefferson — 1 / f %ft v / v "" 3 /f Utilities N. 811 Jefferson I Plan Review/Fire Prevention N. 811 Jefferson &a, I 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 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 Legal Description 1,aT ZX:: / 73:,t/2 Wee 1,4Eu/ evv-rrrz� (3urti0M: (1JQc 4.Rt,toa /,VL Ppm"t ' l=2 - 0 7d PQ 1141.4. oe o r t/ SFifebouF , PPt�s/ Q lotAi,v P Vc fgrai p•3 )7d s 02 3f a{ �rM P789 matZ% 4moi afrift 0. 70 oir G©. Oa