1986, 08-19 Permit App: 00012370 Residence(THIS IS NOTA PERMIT)
BUILDING PERM! f 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)
Project Number f L 3 0
t
Owner's NNaame LAST FIRST M I
P, , /G. S si ifrg S C'C- /'t C.
Project Address (Street Name & Number) Zip
Applicant
Address
City
State
Zip
Phone
( )
Business Phone
( )
Contractor/Agent
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Address
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City
Lim x/£
State
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Zip
P; i f/
Phone
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Contact
License Number (Required)
�se
Business Phone
Architect/Engineer
Address '
City
State
Zip
Phone
( )
Contact
Business Phone
( 1
Lender
Address
City
I State
Zip
I Phone
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Res.
L--'
Comm.
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tams Fist Nurnber
-f irk
., Number
COI eyr
Lot
Stock
Plat Number
Zone
Comp. Plan
Census Tract
# fng Units
Number of Buildings
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Lot Size (Sq. Ft./Acre)
Depth 477, ry .V
VAI, 7J" S,
Frontage
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Left$etback
1
Right Setback
Rear Setback
R/W Width
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1 BUILDING INFORMATION 1
Square Footage
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14447 avp6 J'J w, A
7+0'1' 1 tc000. --
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Number of Bedrooms
Group
Type
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
C
Approvalond.
Hold
Environmental Health Application #
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1
4,
3
P°17/i.(W.
1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson 77`` %' 3Of7
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Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
7—a7`6ia
Rd
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 Pian:
Additional Information:
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
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
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Legal Description
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