1985, 07-31 Permit App: 00006819 Residence(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 Na LAST
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Project Address (Stre/2.4.1:1
Name lumber)
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Applica
IProject Number
Zip
Zip
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Phone
State
Contact
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Architect/Engineer
Phone
Business Phone
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Address
State
Contact
Lender
Phone
Business Phone
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Address
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 is true, correct, legal, and binding.
Owner's Signature "
Date /D -.7S'8•r—
Approved
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CpApprrovov al
Hold
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Environmental Health Permit Number
W.1101 College -
Room 200
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Planning/Zoning
N. 721 Jefferson
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Utilities
N. 811 Jefferson
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Plan Review/ Fire 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 is true, correct, legal, and binding.
Owner's Signature "
Date /D -.7S'8•r—
Show on Site Pian:
Additional Information:
Lot Dimensions
Landscaping
Existing Structures
Drainage Pian
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
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Fronting Street
Flanking Street
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Scale:
Date:
Revisions: Attach
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