1985, 09-19 Permit App: 00007550 Pole Bldg(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 r
Project Number
Owner's Name
Project Address (Street Name & Number)
LAST
FIRST
MI
Zip
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Applicant
e, d 4 l O?/
C;ty
Address) .y %%
Phone
State
Zip isp 90/V
2,2
Business Phone
)
Contractor/Agent
Address
City
State
Zip
Phone
)
Contact
License Number (Required)
Business Phone
Architect /Engineer
Address
City
State I Zip
Phone
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
Describe Work
r6 L8- BLOQ - oPEiv
Subdivision / Pla; Name/ Short Plat Number
iQQ5 - )((3,)`76
Avo To g r,Wp6s
Res
Comm
Assessor Parcel Number
t55 — /lam
Lot
Block
Plat Number
Pertinent File Numbers
Zone
l 7
Comp. Pian.
Census Tract _
Number of Dwelling Units
Number of Buildings
Lot Size ( Ft. /Acre)
I5{., vo
Depth
Frontage
Front Setback:
Left Setback
Right Setback
Rear Setback
Additional Information
Building Technician, r
Date
w
co
1—
Z
w
2
Q
a
w
0
Square Footage
ti
Group - �,.t Type
DEPARTMENTAL REVIEW
el▪ Environmental Health
W. 1101 College
Room 200
Permit Number
Y
Cond.
Approval
44,A2r--'
Approved
Hold
Planning/Zoning
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
Permit Number
Utilities
❑ N. 811 Jefferson
Pian Review/ Fire Prevention
❑ N. 811 Jefferson
Other (SEPA/ Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
1 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
D
Scale:
Dale:
Revisions- Attachments:
0,-
o
Show on Site Plan:
Additional Information:
Landscaping
Lot Dimensions
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
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
D
Scale:
Dale:
Revisions- Attachments:
0,-
o