1985, 10-28 Permit App: 00008394 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
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Owner's Name
Project Addr(Streef Nam umber)
LAST t Lr1 FIRST MI
Zip
Applicant
Address
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City
State
Zip
Phone
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Business Phone
( )
Contrac ^r/Agent
Add ess
City
Contact
State
Zip
License Number (Required)
Phone
Business Phone
( )
Architect/Engineer
City
Contact
Lender
City
State
State
Zip
Address
P..ne
Business Phone
( )
A•. ess
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") //ad s-
Approved
Cond.
Approval
Hold
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Environmental Health Application # l5 N — )-lam
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W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers /
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N. 811 Jefferson ,��✓-- - �' �- i ' _ =__ ��
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Utilities
N. 811 Jefferson
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/ Plan Review/Fire Prevention
N. 811 Jefferson
(0:23--E-;
Other(SEPA/Critical Material/etc.)
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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") //ad s-
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
Scale:
Date:
Revisions: Attachme
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