1986, 05-23 Permit App: 00011245 Residence(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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Owner's Name LAST FIRST MI
5` S Soc,, t c -
Project Address (Street Name & Number) Zip
Applicant
State
Address
Phone
Business Phone
Contractor/Agent
Add ess
W 4- Q /1 o C
State
Phone
Contact
License Number (Required)
f i
Architect/ Engineer
City
Contact
Lender
City
Business Phone
Address
State
Phone
State
Address
Zip 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 to compile said application is true and correct.
Signature Date
Approved
pp
Apprrovov al
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers/� / x.731
N. 811 Jefferson !--/- K — O`�.�
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention C�
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 Date
Show on
. Site Plan: . -Additional - -
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LetDt tr6ons ..
Landscaping,.-'
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Ekisiing Strcturras Drainage Pian.
Proposed improvements Hydrants-
Structure
ydrants Structure Setbacks Topography y ` ' ' ' j -i- - �— -
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Easements.. I:i htrn
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Septic Sstens Sr e _ w. _ E `F
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Water Lines Shorelines'
Sewer Lines Hi hwater Mark
Fences, Wells - E
Driveway(s) 4 - ��
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Right of Way Width(s)
Hames of
Fronting Street
E
Ranking Street
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Legal Description
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Date:
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Revisions: Attachments:
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