1986, 07-16 Permit App: 00012363 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,f
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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
Address
City
State
Zip
Phone
Business Phone
Contractor/Agent
Address
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City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
I Zip Phone
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Describe Work
Res Comm.
Subdivision/ PlatN�aamme�/Short Plat Number
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Assessor Parcel Number
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i Lot Block Plat Number
—
Pertinent Fife Numbers
----
Zone C',omp. Plan Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft.bi cre) _ Depth hrontaga _—
Front Setback
Left Setback
Right Setback Rear Setback R/ W Width
Additional Information
Square Footage
t
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W Number of Bedrooms
$gilding T lcian
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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
Descri
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
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DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health Application # z/
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers '�f
N. 811 Jefferson 2!1Z4 —397��
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 to compile said application is true and correct.
Signature----,- Date