1987, 03-20 Permit App: 87000670 Relocate Residence-(THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE !N INK
(Please return
this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project NumberW. .,
Ex
Owner's Name
\J\L,AST
FLIRT MI
/
-----
Project Address (Street Name & Number)
Zip
Applicant
Address
City
State j Zip
Phone
Business Phone
Contractor/Agent
Address
'1 /6z_
�j
S
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
t )
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
Gty,5
State �
Zip
Phone
Res.
Comm.
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1 �s 0
Lot
Block
Plat Number
Zone
tromp. Plan "
Census Tract
Number of Buildings
Lot Size (Sq. Ft. IAcre)
Depth
Frontage t
Left Setback _ j
Right Setback
Setback
r
—
Rear S _ t
i
2
R/ W Width
Square Footage
.
krt 6-0 N r, � f��-' Prc " fi IF to 6 lill o N
_
Z
o
U.
tRlr
m
Number of Bedrooms
affK' Date
Group Type.
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A
Fol
0
0
DEPARTMENTAL REVIEW
1 certify that I have examined this, tion an -state that the information contained in it and submitted
by me or my agent to compil _ us and correct.
Signatu — Date
Approve
Approval Cp
Approval
Hold
-�
Environmental Health Application S — d a L4 n1
W. 1101 College
Room\ 200
Planning/Zoning
N. 721 Jefferson
t
Engineers
N. 811 Jefferson
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, tion an -state that the information contained in it and submitted
by me or my agent to compil _ us and correct.
Signatu — Date
on
Scale:
Date:
Revisions: Attachments:
ow on Site Plan:
t Dimensions
Additional Information:
Landscaping
Jsting Structures
Drainage Plan
oposed Improvements
Hydrants
ructure Setbacks
Topography
isements
Lighting
T
iptic System (s)
ater Lines
Signage
Shorelines
wer Lines
Highwater Mark
inces, Wells
riveway(s)
ght of Way Width(s)
ames of
Fronting Street
Flanking Street
on
Scale:
Date:
Revisions: Attachments:
Ili