1985, 08-26 Permit App: 00007578 Residence(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET�Z_
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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Project Number
Owner's Name
LAST
FIRST
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Project Address (Street Name & Number)
Zip
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Applicant
Address
0005�7.olYoe
City
State
Zip
Phone
Business Phone
(
)
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
City
State
Zip
Phone
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Describe Work
Res. -,
Comm.
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Subdivision/ Plat Name/Short Plat
Number
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/Assessor
AssessorParcel Number
Lot
Block
Plat Number
/
Pertinent File Numbers
Zone
L
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
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Additional Information
Square Footage
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Building Technician
Date
Group
Type
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Show on Site 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
Sewer Lines
Highwater Mark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Legal Description
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Scale:
Date:
Revisions: Attachments,
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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
W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson _
Engineers Permit Number
N. 811 Jefferson /%�✓/�
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Utilities
N. 811 Jefferson
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 _