1985, 12-11 Permit App: 00009097 Residence4 0 •
(THIS IS NOT A 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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Owner's Name LAST FIRST MI
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Project Address (Street Name & Number)
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Business Phone
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Contractor/Agent
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Phone
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Contact
License Number (Required)
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Business Phone
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Architect/Engineer
Address
City
State
Zip
Phone
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Contact
Business Phone
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Lender
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Address
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Show on Site Plan:
Additional Information:
Lot Dimensions
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
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
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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
CpApproval
Hold
Environmental Health Application #
W. 1101 College �
Room 200 0 r - 'v
Planning/Zoning
N. 721 Jefferson
Engineers /�4-; 7, %
N. 811 Jefferson
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Utilities
N. 811 Jefferson
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Plan Review/ Flre Prevention
N. 811 Jefferson
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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