1986, 06-06 Permit App: 00011432 Addition(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 Safely)
SHADED AREAS ARE FOR DEPARTMENTAL USE -
Project NumbeP",:.c i:.'.
Owner's Namer
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Project Address (Street Name_ 8 Number^�y - ••Zip
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Applicant
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Address
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State
Zip 7 6
Phone ( 561) . 4 2 y tesb-o
Business Phone
(509) xql- 37so
Contractor/Agent
Address
City
State
Zip
Phone
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Contact
License Number (Required)
Business Phone
Architect/Engineer
Address
Ctty
State
Zip
Phone -
Contact
Business Phone
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Lender
Address
,i '
City
State
I Zip
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:Date<^
Groben -1V
Type
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DEPARTMENTAL REVIEW
-
Approved
Cond.
Approval
Hold
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Environmental Health Application 0 lb -1O6 72-7
j.�/ 7
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W. 1101 College �O
Room 200
/' � �/��.L� Mr1ir.1-69:1A. d '-J// Vt 660 n A NSC! //✓tie -r
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Planning/Zoning
N. 721 Jefferson
i.•
Engineers
N. 811 Jefferson
4.
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
W.. - Date
Legal Description
•
ate:
Revisions: Attachments:
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PLOT PLAY E l5 ea / HE'ROY
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.40
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
Legal Description
•
ate:
Revisions: Attachments:
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PLOT PLAY E l5 ea / HE'ROY
SC ?L E- r ,4 ' / o"
.40