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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 t Owner's Name Project Addr(Streef Nam umber) LAST t Lr1 FIRST MI Zip Applicant Address /I/r /72-2- LnceAsfi City State Zip Phone sem' 9,2,z-zo eo 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 `/ / Environmental Health Application # l5 N — )-lam - _0 (� (N it �,itj / / 6. 2/- �; . W. 1101 College Room 200 Planning/Zoning N. 721 Jefferson Engineers / .+ / N. 811 Jefferson ,��✓-- - �' �- i ' _ =__ �� %2 4,1; ./ ! Utilities N. 811 Jefferson I / Plan Review/Fire Prevention N. 811 Jefferson (0:23--E-; Other(SEPA/Critical Material/etc.) vo( 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 L ------ -- --- I E M, M