1986, 06-19 Permit App: 00011741 Garage1
(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)
/0613-7 SHADED AREAS ARE FOR DEPARTMENTAL_ USE
Project Number
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Owner's Name LAST F1RST MI
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Project Address (Street Name & Number) Zip
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Applicant / Address
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City
State 1 ZAP
Phone
( 1
Business Phone
( 1
Contractor/Agent
Ado
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City
State I Zip
Phone
1
Contact
License Number Meow, ed)
Business Phone
( )
Architect /Engineer
Address
City
State
j Zip
j
Phone
( )
Contact,Business
Phone
( )
Lender
City
Address
State I Zip
Phone
(
Describe,Work
(_�)
Res.
Comm.
lsign/Plat Name/ lat Number
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Assessor Parcel Number
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Lot
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Numbek«„Owelting Units
Number of Buildings
Lot Size (Sq. Ft./ Acre)
Depth
Frontage
Left Setback
Right Setback
Rear Setback
R/ W Width
Addtttcna information
Square Footage
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Q
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u.
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5
m
Number of Bedrooms
,
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Group RJ
3
Type
VA1
DEPARTMENTAL REVIEW
I certify that 1 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
Cond.
Approved
Approval
Hold
Environmental Health
W. College
Room 200
Application 1
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1
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Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
•
Utilities
N. 811 Jefferson
1
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/ Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that 1 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
Legal Description
1/4,06 % c,'r'is
Scale: iY► M " /
Date: , -O .rc") T4'
Revisions* Attachments:
CuldeSa��
k
Sel
L
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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
1/4,06 % c,'r'is
Scale: iY► M " /
Date: , -O .rc") T4'
Revisions* Attachments:
CuldeSa��
k
Sel
L
r