1985, 08-30 Permit App: 00007200 Addition(THIS IS NOT A 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)
SHAUtU AHtAb AHt Full Utt'AH 1 MtN 1 AL Ubt
I Project Number WC,
C,
Owner's Name- LAST FIRST MI•
Ilitan %ou9A Suni
Project Address (Street Name & Numb e(I
S�?ip
y
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Applicant
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City
S 2.201 Ca !•inti QJ
State -
Was 4
Zip
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Phone
'26 (.i 6 66
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Business Phone
Contractor/Agent /
Address
City
State
Zip
Phone ,
Contact
License Number (Required)
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Business Phone
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Architect/Engineer
Address
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f
State
Zip
Phone -
1 1
Contact
Business Phone•
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Lender
Address
City
State I Zip
Phone
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Environmental Health
W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Permit Number
Approv%d
Cond.
Approval
Hold
Planning/Zoning,
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson'
Permit Number
Utilities
❑ N. 811 Jefferson
Plan Review/Fire Prevention
❑ N. 811 Jefferson
❑
Other (SEPA/CrItleal 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
y r -
4
Shaw 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
.10 71 2 / /
/9644 /t.
0 4 PAr� y Qaww ;In
Date: 23/361a,5"
Revisions'