1985, 07-22 Permit App: 00006480 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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number
Owner's Name
Project Address (Street Name & Number)
/2O / J-orvf
Applicant
LAST
FIRST MI
L/f4v04.-/ 7 t eei.
Address
Zip
9ro/�
State
Phone
Business Phone
Contractor/Agent
Address
State
Contact
Phone
Business Phone
Architect/ Engineer
Address
State I Zip
Phone
Contact
Lender
Business Phone
Address
City State Zip Phone
r
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
Cond.
Approved
pproval
Hold
�?
, Environmental Health Permit Number / < (��
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//11
W. 1101 College / 14
Room 200
- lathet„.,'
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
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 is true, correct, legal, and binding.
Owner's Signature Date
.. Additional Information:
Lot Dimensions
Landscaping
Existing Structures
Drainage Plan,
--
Proposed Improvements
Hydrants
Structure Setbacks
Topography
Easements
sighting
Septic System (s)
Signage
Vater sines
Shorelines
Sewer tines
Highwater Mark
- -
Fences, Wells
Driveway(s)
Right of Way Width(s)
Karnes of
Fronting Street
Flaming Street
Scale:
Date:
Revisions: Attachments:
L v i "A v } c c D F --N