1986, 07-17 Permit App: 00012149 MH(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)
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DEPARTMENTAL REVIEW
Cond.
Approved Approval
Hold
Environmental Health Application ff \
W. 1101 College i
Room 200
Planning/Zoning
N. 721 Jefferson
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Engineers 4
N. 811 Jefferson
Utilities
N. 811 Jefferson
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Plan 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 agent to compile said application is true and correct.
Signature Date
Show 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
l-Iydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
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