1985, 08-26 Permit App: 00007450 Residence(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET n-7. 5t''
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
Owner's Name LAST FIRST MI
S v --77`d• c /5-7-7 zit/ C
Project Address (Street Name & Number)
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Zip
C
Applicant
GU. /I J' y MsseC rfrtr7e'r
AC/C
Address
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City
State
Zip
Phone
Business Phone
Contractor/Agent
Address /a. C /Sex /YC�l�
City
State
/-///9-s" /7
-
Zip
Vii' y- 7
Phone
Contact
/(C b7- V7
License Number (Required)
Business Phone
(
7 - e 1d- z
Architect/Engineer
Address
City
State I Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
,delE .Ce/!' Flee' t
86
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
Approved
Cond.
Approval
Hold
Environmental Health Permit Number
.5--_4)7-7
5_14
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Permit Number
pi/i
/Engineers
811 Jefferson 7%4
,/N.
ya
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
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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
Show on Site Plan:
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
Legal Description
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