1986, 06-27 Permit App: 00011855 Addition(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
Owner's Name
LAST FIRST MI
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Project Address (Street Name
& Number)
Zip
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Applicant
Address
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City
State
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Phone
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Business Phone
Contractor/ Agent
1
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
Architect/ Engineer
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Address
City
State
Zip
Phone
Contact
Business Phone
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Lender
Address
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CityState
Zip Phone
Descnbe Work
C46iuzms
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Subdivision/Plat NamelShort
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Plat Number
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Assessor Parcel Number
` Lot Biock q 'Plat Number '
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Pertinent File Numbers
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Number of Bwidmgs Lot Size (Sq Ft /Acre De th r s 2,
P Frontages
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Setback
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�AddiUonal information
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Square Fogtage
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DEPARTMENTAL REVIEW
4
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
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Approved
Cond.
Approval
Hold
Environmental Health Application ff 6 T1717o-CZ
W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
(41
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
C
-
Septic System (s) Signage
Water Lines Shorelines
Sewer
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Lines Hi hwaterMark _; - __, _�__ __ _._ _ __-�--�--- �--�—�' --� .—:_ -� _ n i � � - � - _. - . __ I _... _
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