1986, 08-01 Permit App: 00012435 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 Safety)
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Project Number 'Z
Owner' NameLAST F RST
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Project Address (treet Name & Number)
Zip
Applicant
Address
City
State Zip
Phone
Business Phone
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City
StateZip
Phone
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Contact
License Number (Required)
Business Phone
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Architect/ Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
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1
Lender
Address
City
State
Zip
Phone
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1
Describe Work
1
Res. /
Comm.
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Subdivision/ Plat Ne!/S� ort Plat Number
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Assessor Parcel Number Lot
Block
Plat Number
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Pertinent File Numbers
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Zone�^�
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Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./ Acre)
Depth
Frontage
Front Setback
Left Setback
Right Setback
Rear Setback
R! W Width
Additional Information
Z
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Square Footage
H
Q
2
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-
LL
Z_
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Number of Bedrooms
Building Technician
Date
Group
Type
Show on Site Plan:
Lot Dimensions
Additional Information:
Landscaping
Existing Structures
Drainage Plan
Proposed Improvements
Hydrants
Structure Setbacks
Topography
Easements
Lighting
Septic System (s)
Signage
_
Water Lines
Shorelines
Sewer Lines
Highwater Mark
Fences, Wells
Drivoway(s)
Right of Way Widths)
Names of
Fronting Street
Flanking Street
DEPARTMENTAL REVIEW
01P 0
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
❑
Planning/Zoning
N. 721 Jefferson
❑
Engineers
N. 811 Jefferson
❑
Utilities
N. 811 Jefferson L 7
❑
Plan Review/ Fire Prevention r
N. 811 Jefferson
]
Other (SEPA/ Critical Material/etc.)
]
Fast Track/Special Inspection Information
Project Representative TPhone
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 /E__�`��f�'� i�'��;s� l' Date 4� f