1986, 05-16 Permit App: 00011091 GarageIt 2A
(THIS IS NOTA PERMIT)
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this iginal and your building plans to the Department of Building and Safety)
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Project Number
Owner's Name LAST
FIRST
MI
7-4
Project Address (Street Name & Number)
Zip
S 3063 Ozw5-
lQ.2l
Applicant
Address
City
State
Zip
Phone
(
?I
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---
I Zip
--
Phone —
-- --
Describe Work _
Res.
Comm.
Subdivision/ Plat Name/Short Plat Number
IT
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 i
Front Setback
Left Setback
T]1�
Right Setback
Rear Setback
,
R/ W Width
1
7.
Additional Information
Square Footage
Z
O
H
Q
O
Z_
_
C7
Z_
J
M
Number of Bedrooms
Building Technician
Date
Group
Type/�
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 (Nark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Ramos of
Fronting Street
Flanking Street
-�6-
Scale:
Date:
Revisions:_
i
0
Fol
11
0
A
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 to compile said application is true and correct.
Signature Date
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
610 OUS 7A OdY70
OV
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
SIGNATURE OF
OWNER OR AGENT
JOB ADDRESS
APPLICATION
DATE
PROJECT
INSPECTOR'S COPY
OWNER:
ADDRESS:
CITY:
ST:
ZIP:
APPLICANT:
CONTRACTOR:
ADDRESS:
CITY:
ST:
ZIP:
PH:
LICENSE.:
ARCH/ENGINEER:
ADDRESS:
CITY:
ST:
ZIP:
PARCEL-
CENSUS TR:
INSPECTOR:
PLAT.:
LOT _ BLOCK
FINAL
PLAT NAME:
ZONE.: ZONE
FSB
S-1
S-2
RSB
MOD
USE OP PERMIT:
JOB ADDRESS:
APPLICATION
DATE
PROJECT
INSPECTOR'S COPY