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
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I