1986, 03-03 Permit App: 00009856 Reconstruct Residencee
` (THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
c COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
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Project Number cie2rL—
FIRST MI
Owner's Name /' LAST Cron"?
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Project Address (Street Name & Number) / Zip
/7.S_a- C %lLeray 1?„ .en4Je. 4}a. ,92/C
Applicant
Address
City
State _ ..
Zip
Phone
Business Phone
Contractor/Agent"ctg/"� //
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Add ass ST / 7t/�
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City
0.f5voftl
State
ti
Zip
99 2 a 61'
Phone
(.3-07) 72? k -R1 "/O
Cont ct
License Number (Req 'red)
d'/C/e7y EC /C/e7
Business Phone
( ) 9.z,P- Is',s`,O
Architect/ Engineer • Address
City
State _ _
Zip '
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
( )
Describe Work
Res,oei,Jee (��ECOMSnaten o/0)
Res. /
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Comm.
Subdivision/Plat Name/Short Plat Number
\/AnrosvER Sus
Assessor Parcel Number
03S -'/ -, Moat
Lot
l
Block
3
Plat Number
.
Pertinent File Numbers-
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
1
Number of Buildings
I
Lot Size (Sq. Ft./Acre)
Depth
/25
Frontage
qio
Front Setback '
eY'STp-JG
Lett Setback
Right Setback
Rear Setback
R/W Width
Additional Information
I BUILDING INFORMATION
Square Footage
vb = ue
4100 =F+3
Number ot.Bedrooms
Building Technician
Cinaid
Date
03-o3-E3b
Group
(2-3
e
Type
vn)
0
DEPARTMENTAL REVIEW
Approvedl/
Hold
Environmental Health ApplicationWS
1101 College XX ((
1 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 ''.� cP,C
ttoiLiond.
RoomVSicKG-
Tenik —
Planning/Zoning
N. 721 Jefferson
Engineers
N.811 Jefferson
Utilities
N. 811 Jefferson
Pian Review/Fire Prevention3'V`�
N.811 Jefferson
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Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
1 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 ''.� cP,C
Scale: �)
Date:
Revisions:
Attachments:
Show on Site Plan:
Additional Information:
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
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Scale: �)
Date:
Revisions:
Attachments: