1985, 10-30 Permit App: 00006770 Residence41141v�J�i , 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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number 7 'r )
Owner's Name
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LAST
FIRST
2 ,c
MI
Project Address (Street Name & Number)
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Zip
Applicant
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City
State
Zip
Address
Contractor/Agent
Contact
r< <
State
Zip
Phone
(
Business Phone
( )
Address
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License Number (Required)
Architect / Engineer
City
State
Zip
Phone
Business Phone
( )
Address
Contact
Lender
City
State
Zip
Phone
Business Phone
(
Address
Phone
(
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 Date
Approved
Cond.
Approval
Hold
/ Environmental Health Permit Number
1
%
."Lf'f
1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Permit Number
. 4
71,
Engineers
811 Jefferson
'
Utilities
(--N. 811 Jefferson
I
/
7 Plan Review/Fire Prevention
N. 811 Jefferson
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Other (SEPA/Critical Material/etc.)
9.--3---
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 Date
N
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Z
90
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Show on Site Plan: Additional Information:
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Structure Setbacks
Topography
Easements
Lighting
Septic System (s)
Signage
Water Lines
Shorelines
Sewer Lines
Highwater Mark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
6 ;-'r
Scale:
Date:
Revisions: Affachme
6
9
YN
6
9