1985, 12-04 Permit App: 00009030 Residence(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)
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Project Number q;'1 3 ,�
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Owner's Name LAST FIRST MI
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Project Address (Street Name & Number) Zip
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Applicant
Address
City
State
Zip
Phone
( )
Business Phone
( )
Contractor/Agent
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Address
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City
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State
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Zip
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Phone {/'j 2 - ( 7 .r2.___
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Contact
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License Number (Required)
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Business Phone
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Architect/ Engineer
Address
City
State
Zip
Phone
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Contact
Business Phone
( )
Lender
Add ess
City
State
I Zip
Phone
Describe Work
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Res.
Comm.
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Assessor Parcel Number
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Lot
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Block
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Plat Number
Pertinent File Numbers
Zone(.....Comp.
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Plan
Census Tract
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Number of Dwelling Units
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Number of Buildings
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Lot Size (Sq. Ft./Acre)
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Depth
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Frontage' -
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Front Setback
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Left Setback
Right Setback
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Rear Setback .
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DEPARTMENT USE
Square Footage
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Building Technician
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Date
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Group.:.. ...r>.
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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
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
1
Legal Description IL?7'
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Environmental Health
❑ W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Permit Number FS— /7/�
Approved
Cond.
Approval
•
Hold
Planning/Zoning
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
Permit Number
•
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Utilities
❑ N. 811 Jefferson
Plan Review/Fire Prevention
❑ N. 811 Jefferson
Other (SEPA/CrltIcal Material/etc.)
Fast Track/Speclal 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
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