1985, 09-10 Permit App: 00007526(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
•L1
(Please return this original and your building plans to the Department of Building and Safety)
ont-wcu Mnc/Ao Hnc run VrF1n I IVICIN I NL uJc
Project Number
Owner's Name LAST FIRST MI
olect Address (Street Name & Number) r Zip
VW. :5 7 Lc..7f? -m 9/4,20
App icant ( Q j/�f /(+ /7/�/"� J/����
�L!! 'l`� / lie
I Addres )
j 'J ((
City
c' a4...,2..
State I Zip
Lt.) 74 , i_ 9 c2c)6,
Phone
(� 9) 9e2?— ip 9 7
Business Phone
- 4
Contractor/Agent
Addre
kd . -1' c
2 (Gc - c u
" 4i 0alii_Inaa:-r_
City
G4
State
4 '
Zip
9 G} c,
Phone
(,3--z) qa y _ /0, ?
Contact ii
.4
License Number (Required)
(°( t > -- /lieP
4(-2 S:�kc
Business Phone
( )
Architect/Eagineer
Address
City
State
I Zip
I
Phone
( )
Contact
Business Phone
( )
Lender
!
LI,T'< dl -,d L' Cf /IlLe- ---?
Address
I'
C() ' (C 0 J (.C..tOtj
City
40.--,....2—
State
(,-(_,I1 `
I Zip_Phone
9 U 1
( 5-09 (I5 S---7 -7 i
Describe
Res.
Comm.
Subdi on/Plat N me/Short Plat Number
/ L
Parcel Number
Lot
Block
Plat Number
Pertinent File Numbers
Zone
Fa -z -
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
1
Lot Size (Sq. Ft./Acre)
Depth
1ZS
Frontage
clC� t
Front Setback 4
'5-7
Left Setback
Right Setback
z.c
Rear Setback
Additional Information
DEPARTMENT USE
Square Footage
M r �- C
u 1 oc .
B' ding Technician
Date.
Gr p
I
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
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Permit Number
.. r.
Engineers
N. 811 Jefferson /--- 3-g
0°
Utilities
N. 811 Jefferson
el./ 1.
Plan Review/ Fire Prevention;/-!
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Inform: tion
Project Representativ ,_,A 2A___.91s.„,
Phon /d /O 477
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
Show on Site Plan:
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
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
t
2O 6E