1986, 06-18 Permit App: 00011665 Garage(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
Project Number
I
Owner's Name LAST FIRST
t- -1 2I 6-5 D A -O I MI .
P
Project Address (Street Name & Number) Zip
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Appl' nt
A-0IA. -S-C-1121CS
Address
5- (109 -BO 2►`►S £.
City ���b��r
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State A
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Zip
` 11
Phone
Phone (SO� q2 -6,-7002 -
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Business Phone
(Sod G1;26-1(8
Contractor/Agent
SA m c
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect/Engineer
Address
City
a
State
Zip
Phone
( )
Contact -
Business Phone
( )
Lender
Address
City
State
Zip
Phone
( )
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Plat Number
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Pertinent Fila Numbers
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Depth
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Front Setback
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AIW Width
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Building Techntciaat30
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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 age to compile said applicatio is true and correct.
SignatureZ1-4(4-
!-'' Date `
Approved
Cond.
Approval
Hold
Environmental Health Application # 6---/ef,
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W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
•
Utilities
N. 811 Jefferson
I
Pian Review/Fire Prevention
N. 811 Jefferson
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 age to compile said applicatio is true and correct.
SignatureZ1-4(4-
!-'' Date `
Lot Cost
PLOT PLAN
/
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:ale:
isic:
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)del:
r..01 •n'.2 v e,4C.5
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ELEVATIONS:
Crown of Street
Finish Floor se.,/ a --
Sq. Ft.
Job #
S,s
Legal
j. d - Snoz,p4f :s
Address
S. //C
)rt --'e Co.
eglaor el #
a354/.v- 0700
Backwater Valve:
No
)wer Co.
Water Co.
Garage:
Front Alternate:
umber Excavator Sewage:
el
Fire Place:
4-C hargq c.0
Special Items:
Scale.
Date:
Revisions: Attachments:
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Show on Site Plan:
Additional Information:
Lot Dimensions
Existing Structures
Proposed Improvements
Landscaping
Drainage Plan
Hydrants
Structure Setbacks
Topography
Easements
Septic System (s)
Lighting
Signage
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Shorelines
Highwater Mark
Scale.
Date:
Revisions: Attachments:
MEI 11111111111111111M1111111111111111111111111 II
IIIINIIIMMI11111111111111111111111111111111111111111111111MMall '' •
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IIIIIIIIIIhmmllIllMIMIIIIIIIIIIIIIIIIIIIIIIIIIMINIIImmmmll I
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ammmimommina ME 1111111111111111111=10111
■
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minvimumMis!glil 11111111.1=11
mmis EMI
IEEE
1
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111M1111111111111111111E1111 11111111111111
11
IEEE
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MEM
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