1986, 02-12 Permit App: 00009692 Addition(THIS IS NOTA PERMIT)
BUILDI G ER
IT APPLICATIO WO
1,*
KSHEET
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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Owner's Name LAST FIRST Mi
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Project Address (Street Name & Number) „) Zip
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Applicant
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Address
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City t ) State
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Zip
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Phone
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2;entractor /Age)
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Address
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Business Phone
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City ,)
State
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Zip
Phone
Contact
Archited / Engineer
Liconse Number (Required)
Address
Business Phone
( )
City
State
Zip
Phone
( )
Contact
.-----__—
Lender
Address
Business Phone
( )
City
State
Zip
Phone
(
)
1 - scribe Work
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Res.
Cornm,
SubdhAsion/Plat Name/Short Plat Number
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A,ssessor Parcel Number
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Lot
Biock
Plat Number
Pertinent File Numbers
Zone
Comp, Pien
census Tract
Number of Dwelling Units
.....____ .0........_
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
i 0 0
Front Setback
Additional Information
Lett Setback
Right Setback
Rear Setback
Square Footage
RWidth
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0
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4X.
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0
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Nurnber a
.'tiding Technician
DateGroup
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She. on Sita plan: Additional information
Lot Dimensions
Landscaping
Existing Structures
drainage plan
Proposed Improvements
Hydrants
Structure Setbacks
Topography
Easements
Lighting
Septic System (s)
Signage
Water Lines
Shorelines
Sesser Lines
Highvsator Mark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Flames of
Fronting Street
Flanking Street 1
■
Environmental Health
W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Planning/Zoning
N. 721 Jefferson
1111 III II 1111111 11 1111111 11
MENEMIMEMMAIMIEN
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
E=INAMSEINEM
Plan Rmw|eo/F|noPrevention
N.V11Jefferson
MIEROMIONHHEIMMICIEMEMMEMM
Other (SEPA/ Critical Matorlal/otc.)
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Fast Track/Special Inspection Info motion
Project Representative
Address
5001109WOMMEMMI
Phone
| certify that | have examined this application and state that the information contained in it and submitted
by me or my agent 10 cornpile said applicatlon 15 true and correct.
Signature �-
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/ Date