1985, 12-23 Permit App: 00009232 Additionr
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(THIS IS NOT A.PERM IT)
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 ,
-Own -' Name - LAST FIRST MI
of t Address (Stree arae & Num er) Zip
Address
City
State
Zip
Phone
Business Phone
Contractor/Agent
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
( )
Architect/ Engineer
Address
City. State Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
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Plat Number
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Comp Plan
Census Tract
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;Number of Dwelling Units
Number of Buildings
Lot Size (Sq Ft lAcre)� 7�
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Left Setback
Right Setback $
Fear Setback 4
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DEPARTMENTAL REVIEW
09
Approved -J
Cond.
Approval
Hold
Environmental Health Permit Number 0
W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
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�3A! Fu4NXON
Engineers. Permit Number
'11 to.
Jefferson
Utilities
N. 811 Jefferson
Plan Review/ Fire Prevention
N. 811 Jefferson
CP er(SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative :
Phbne.
Address
I certify that I have examined this application and state that the information `contained in it and submitted
by�me WMgent i true, actlegalan binding..
/
Owner's Signature __ Lf ---_-___ Date------
/I
Stiow'on Site Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Struciure 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
4� t (0 3 L oc-te- v
Scale:
Date:
Revisions:. Attachments:-
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