1985, 09-04 Permit App: 00007451 Residence(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
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(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
Project Address (Street Name & Number)
Zip
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Applicant
Applicant
Address
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City
State
Zip
Phone
/
Business Phone
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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
Describe Work
Res.
Comm.
Subdivision IPlat Name/Short Plat Number
Assessor Parcel Number
Lot
Block
Plat Number
#�
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Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./ Acre)
Depth
Frontage
�e
Front Setback
Left Setback
Right Setback
RearSetback�
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Additional Information
Square Footage
Z
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W
F—
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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
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
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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 c�� �� ..«,. ------Date
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Approved
Cprov
Approval
Hold
Environmental Health Permit Number r, ju T
W. 1101 College
Room 200 2�
Planning/Zoning
N. 721 Jefferson _
Engineers Permit Number
N. 811 Jefferson
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 c�� �� ..«,. ------Date
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