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1986, 05-06 Permit App: 00010839 Enclose Deck(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) SHADED AREAS ARE FOR DEPARTMENTAL USE Owner's Name LAST FIRST MI Project Address (Street Name & Numb ) , ,�/ Sav"74 C�z, eG4P-�(T Zip Applicant Si k?". City S ,d0 /rs Address State IqS Zip Phone (q�2) ''t?'Y Business Phone Contractor/Agent City C o ,, 3-4. C State Zip 9� 2 0 Address So,t-`s C/a'i Phone (?8 ,c3 6 Contact I 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. Date G ` Approved CpApproval Hold Environmental Health Application # W. 1101 College Room 200 Planning/Zoning N. 721 Jefferson Engineers N. 811 Jefferson Utilities N. 811 Jefferson Plan Review/Fire Prevention N. 811 Jefferson -5 -43,6 f 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. Date G ` - YA 4, A `•.fr t111 ' -ft, Lc Rejtck_ 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 N j - I