1986, 11-03 Permit App: 00013966 Garage(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)
Owner's Name
SHADED AREAS ARE FOR DEPARTMENTAL USE
LAST FIRST MI
[Project Number ''154ca.0
Project Address (Street Name & Number) Zip
///// 4/Ru/ Gr/ c/7,;-4
Applicant
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Address
State
Zipq /
Phone
(jay) c7�-�
Business Phone
Address
State
Contact
Architect /Engineer
Zip
License Number (Required)
,67 -1A/7= /77�/�
Phone
Business Phone
(
Address
City
Contact
Lender
City
State
Phone
Business Phone
Address
Phone
7) 9 4 6
at Number
Frontage
0
D
g Footage
Number of Bedrooms
Group',
M- 1
Type
DEPARTMENTAL REVIEW
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
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Approved
Cond.
Approval
Hold
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Environmental Health Application # �
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W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
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111
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Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
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7PIan Review/Fire Prevention
N. 811 Jefferson
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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
Show on Site Plan:
Lot Dimensions
Additional Information:
Landscaping
Existing Structures
Drainage Plan
Proposed Improvements
Hydrants
Structure Setbacks
Topography
Easements
Lighting
Septic System (s)
Signage
Water Lines
Shorelines
Sewer Lines
Highwater Mark
Fences, Wells
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Driveway(s)
Right of Way Width(s)
,
__
Names of
Fronting Street
j@
Flanking Street
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Legal Description_
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