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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) JrIAUtU AlltAJ Hilt rum UtYAil I MtIV I HL UJt a',.e !atr .ppaa' Owner's Name LAST FIRST MI iWItLoL D —7—"D ZiJt M.4.•,-7 Project Address (Street Name & Number) j" --..1, S i3(a Lo Zip -- Tet_ PawE _ ( ,7,4A, - -d- Applicant— ����// t� // / I2 %''y`2/Vc. —/ /VO,e /19u1.a.3 l ¢M&.S) Address �+ t ?( /4/2°23 City S to Zip w.v ,., ,-5 21,,i_ Phone (. ) /2Z0 _b is ce.b..-...,..., P4• &C A/2` 3 Business Phone ( ) .5.41#1E__ Contractor/Agent Sim p 1,sz-5S I41c_-) A--- tCity Address City State Zip Phone ( ) Contact License Number (Required) _ Nom -4-4 N 2,i3 fl Z Business Phone ( ) Architect/Engineer Address City State Zip Phone ( ) Contact Business Phone ( ) Lender // 's Z.)/9S. / J')7,--,..___ h Tii4 e. — Address City 3State Zip Phone ., �uE�x� t� k. & . 'a �u��„• A�+_ #ti k� "'� �.'#a� Y �.4s'� 6a' �k� dxq„ {� � �%k��¥'"nbi _ .,a� r� 4 ip �'#d$ �., a_� '$� +y .tom. ..: ., 4e.,,..:. �` , 8 ,:rm. m. tk .,,, „���Y ✓iq, �„';y.P $";"'aY:l D ° . �a'b :° 9 k 4 f y & „i%.. -. wC�*i.� r .aa,.. .,:.., :.... .x .. viA a . §ti'. ..�Smsa'.... 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 ulen- z),e/1.)z-- 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 1' Utilities N. 811 Jefferson I Plan Review/ Flre Prevention N. 811 Jefferson _ j 00\ SA -m I'S too 0 A/4 R cX• ( NO tlizt.. Pps_mc„•rr 4-EtCP611- 6tv^, ) 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