1985, 10-09 Permit App: 00007965 ResidenceK . Sm (n.
(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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
er's Name LAST NST MI
cGr [ ercLr0 !ti' 1I
roject Address (Street Name & Number)
!`' UT I � "- ' L— ' 6. -7 - TA
np
ApiRlicant
a4/
Zip
Cit2f-06
Address
S. 27a6 6/uk-k
City
Sro/Ca4.�
State. 4
Zip
RT?l6
Phone
( ) q.17 - a ?s6
Business Phone
S'Q%l1 e,
Contractor/Agent
Sel-F
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
( )
Architect /Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
(
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 "1' Date I 0((/ 1S
Approved
Cond.
Approval
Hold
Environmental Health Application #
�j�
W. 1101 College
Room 200 i �' 1Tkd ik/r'
l L A kr r
Planning/Zoning
N. 721 Jefferson
Engineers-
N. 811 Jefferson /1/14.'
Utilities
N. 811 Jefferson
I
/Fire Prevention
Plan Jefferson
N. 811 Jefferson
s � T /iY.--
/I �C.f/ �
19661Y—
Other (SEPA/Critical Material/etc.)
Other
Fast Track/Special Inspection Information
Project Representative
i
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 "1' Date I 0((/ 1S
Show on Site Plan:
posed Imp ovements_
Structure Set ! ; cks
Easements.
Septic Syste (s)
Waterlines
Sewer Lines
.14ncesi,Weiis.;
Additional Information:
Hydrants
Topography
Lighting
Signage
Shorelines
Highwatar Mark
Fronting Streit`
Flanking Street
A
Legal Description
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