1986, 03-10 Permit App: 00009964 Garage•
(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)
'"nv1-1-#n"I-l LI V II V C"n I Ivi CIN I ML "c' kroleci Number ef9Gj
Owner's Name LAST FIRST MI
/V ele ^n6}e/7" 0 cot -9 ,e_
Project Address (Street Name & Number) Zip
/7 Li-t7e 0- 1{f 190 f/ 992`(
Applicant
J'ael.."er m, 00y1/4r72
Address
59/ J-' r/,oeue%,r/-ZZy
City
Salo ir'e9- F
State
tAi A
Zip
?")4 Q G.
Phone
( )
Business Phone
( )
Contractor/Agent
So ret-rn (/ Co /VC/
Address /'
' ,T- (/.
l ' weeps' /74
City
SO°O%�.n 4l �
State f� �
tel/ n
Zip 9� 0�
Phone ITti
(p� lf
Contact
.Scor
License Number (Required)
-.6C (61Ot
Business Pone
(h ) •. e
Architect/Engineer
Address
City
State
Zip
Phone
( I .
Contact
•
Business Phone
1 )
Lender
Address
City
Stale
I Zip
Phone
( )
Describe Work
iv ej ' >9 ali• ; e 67aO_
Res._
Comm.6Vr,
Subdivision/ Plat Name/Short P1st Number 2.. S'ro R y
(//9v6.V,' J)6
Assessor Parcel Number .. -
oast/! - 360i
Lot
• r
Block
3
Plat Number
Pertinent File Numbers
Zone -r -r re
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft/Acre)
Depth
Frontage
Front Setback
Leh Setback
Right Setback
Rear Setback
R/ W Width
Additional Information - _
BUILDING INFORMATION
Square Footage/ Id
576 —CA2
576 — 2.F
5S = aEeK
Number of Bedrooms
Building Technician
9/
Date
9346%- ,
-
Group
133/H_ r
Type
V 0
J Environmental Health
L`7 W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Application # 4 f
Approved
Cond.
' Approval
Hold
Planning/Zoning
0 N. 721 Jefferson
Engineers
0 N. 811 Jefferson
Utilities
0 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
vow "`' cf,7;,,,
Date 7 --yd —PC
.4
/
Show on Site Plan:
Additional Information:
Lot Dimensions
Existing Structures
Proposed Improvements
Landscaping
Drainage Plan
Hydrants
Structure Setbacks
Topography
Easements
Septic System (s)
Lighting
Signage
Water Lines
Shorelines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Highwater Mark
Legal Description
Date:
Revisions: Attachments:
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