1985, 08-12 Permit App: 00006829 Addition(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)
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Project Number /,�ji7 6/
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Owner's Name LAST FIRST MI
Project Address (Street Name & Number) Zi
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ApplicantAddress
City
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State
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Zip
Phone
( )
Business Phone
( )
Contractor/Agent
—set/e/C (a/05-74 UC -7 1-).-J
Address
t /t"i/,6 3(7Z-11
City
_s�.r,�i9 N e
State
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Zip
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Phone
( )? f ?6D
Contact
License Number (Required) �
Business Phone ) 5 Z k ?; ciCi
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
( )
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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, leg nd binding.
Owner's Signature
(7
Date '' / s ./
Approved
Approval
/Environmental Health Permit Number
W. 1101 College
Room 200
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Ili �3
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Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
�-J ,-----
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, leg nd binding.
Owner's Signature
(7
Date '' / s ./
ADDRESS: /V 505 / lA,4 /? PD PROJECT N:
Genal -
Ownership Health
0 Applicant Increased Lot Coverage?
IaContractor Addition Bedrooms/
Fixtures?
❑ Architect Change of Use?
New Septic?
E Addddress
8 LLegal Description
la'Parcel Number
erZoning
C' ite Plan
❑ Plat Map
&Permit Description
Plannin
Unplatted Property?
Lot Depth: Width > 3:1?
(less than 10 acres)
Lot Depth: Width > 4:1?
(10 acres plus)
Lot Size Less than Minimum?
Segregation of Platted
Property?
Setbacks Less than Required?
Frontage less than Required?
LW 1 ans Not a Permitted Use in Zone?
❑ Completeness Rezone, Conditional Use,
Variance Involved or Required?
❑ Square Footage Commercial Use or Home
Occupation?
❑ Occupancy Group d Type More than One Residence?
❑ Departmental Releases Adjacent to a Required
and Conditions - Shoreline?
REVIEWED BY:.
En•ineerin
New Access/Approach?
Private or Unmaintained
County- Road?
Se•a
Yes No N/A
Underground Tank Over
10,000 Gallons
Commercial Building Over ✓
12,000 Square Feet?
Over 20 Dwelling Units?
Over 40 Parking Spaces?
Agricultural Building Over
20,000 Square Feet?
Landfill or Excavation Over
500 Cubic Yards?
Critical Material
Designated as a Critical
Use Activity?
DATE: g --/"P'-5
Show on Site Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Legal Description
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Scale:
Date:
Revisions: Attachments: