1986, 12-12 Permit App: 00014519 Repair Fire Damage(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 /f
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Owner's Name LAST �FIIRRSSTT`/J MI t
7:10A
Project Address (Street Name & Number) Zip
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Applicant
Address
City
State
Zip
Phone
( )
Business Phone
( )
Contractor/Agent
Address 4
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City'
State !/
Zip
972.e7
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Conta 1 License Number (Required)
O 7/N9
Business Phone
( )
Architect/Engineer
Address
City
State I Zip
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Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
I Zip
Phone
(. )
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Rear Setback
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Show on Site Pian:
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
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health
❑ W 1101 College
Room 200
Permit Number
Planning/Zoning
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
Permit Number
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 is true, correct, legal, and binding.
Owner's Signature Date