1986, 01-31 Permit App: 00009554 Residencereg
(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)
StiAUtU AHtAS AHt t -UH UtYAH I Mtr4 I AL USL
Project Number
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Owner's Name 4...c �?� LAST FIRST MI
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Project Address (Street Name & Number) Zip
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Address
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Phone
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Address
City
State
Zip
Phone
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Contact
License Number (Required)
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Business Phone
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Architect /Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
( )
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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 /--07
6—b
Approved
Cond.
Approval
Hold
/
Environmental Health Permit Number
/� lf
,
•-_,
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Permit Number
/ /'_
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Engineers
N. 811 Jefferson ni71
e2_
_
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
PR--
r
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 /--07
6—b
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
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