1985, 08-15 Permit App: 00007026 Residence(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
Project Number
Owner's Name LAST FIRST
MI
r /,' . S (;e -
Project Address (Street Name & Number)
Zip
3 c -5 21 [)ffz'/ S
Applicant
Address
S r c , N ;, -v5 !.0 '
1P !
City
State
Zip
Phone
Business Phone
(
)rte
Contractor/ Agent
Address
City
State
Zip
Phone
(
)
Contact
License Number (Required)
Business Phone
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
Crit-
/V 3eeq
/fif�ll.��ri
City
State Zip
Phone
Describe Work k W1,
VON
Res.
Comm.
Subdivision/ Plat Name/Short Plat Number
/ i /plcF r"tom
Assessor Parcel Number Lot
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./ Acre)
Depth
Frontage
(
Front Setback
Left Setback
Right Setback
Rear Setback
iA. tt
J
—
Additional lnfor iom
W
Square Footage
vJ
H
Z
W
h
Q
Q
a
W
0
Building Technician
Date
Group
Type
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
Legal Description
f/
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
r
Scale:
Date:
Revisions: Attachments:
'GOA
EWA
■
■
/■ElO
�_
Bpi
I
NNE
0■-1001
MEN
No
IN
mr,
SOM
mm
_MllM
No
MIMME
I
M
m
M
ME■
NONE
I
ME
IMENOINE
ME
ME
MEN■M
CTM�
MEN
ME
M
NNE
■mmm
NNE
�m�ommoom
ME
No
m
MIM--
INN
ME
ME
IMMEM
ME
MENEM
ME
MENEM
MMMo■MEMO
N
m
MENEM
rm
's
9
i�
a
N
N
N
0
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 is true, correct, legal, and binding.
Owner's Signature ___ __- __ - - __ _— _ Date
Approved
Cond.
Approval
Hold
Environmental Health Permit Number D
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson _
_Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
1
Plan Review/ Fire Prevention
N. 811 Jefferson
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 is true, correct, legal, and binding.
Owner's Signature ___ __- __ - - __ _— _ Date