1986, 04-15 Permit App: 00010480 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)
SHADED AREAS ARE FOR DEPARTMENTAL USE
1:5ruiect Number' I•
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Owner's Name LAST FIRST Mi
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Project Address (Street Name & Number) Zip
C- 3/° 8 /1;f//re�" S o ,(1,94/ e- 9902°4
Applicant
JA e /MJeTeLLC
Address
S'. 3/06' /yMA/i> • y
City
spo 4.g l,e.
State
Ge/.S's/ii
Zip
99'DE
Phone
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Business Phone
Contractor/Agent
•CraX4, /12. 47os
Add
ess
14 is STEPflsPt)E CT
City
47e4,0
State
�i✓.9s/,'
Zip
99v071
,3acjo
Phone
(3709) .546 - 4/825
Contact
License Number (Femur
ed)
Business Phone
Architect! Engineer
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Address
City
State
Zip
Phone
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Contact
Business Phone
Lender
Atltlr¢55
City
State
Zip _
Phone
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Describe Work<:we:„.:'• iY"•` .:p:=•
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Subdivision/Plat Name/5hor
t Numbers
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Assesr. Parcel Number -6 :' S: {:'.,'-::':;;
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Lot
'Block'' "C ..
.Plat Number
Pertinent File Numbers _ +;': �� •- - . ,- `^' • :
Zone
Comp. Plan ' ' " ="" -
'Census Tract
iNumberof Dwell in° Un its&{ 4' �,i .:.;-'
,Number of Buildings
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Lot Size (Sq Ft./Acre) ..
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Depth , ..': > :
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Frontage
'.Front
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Rlgnt Setback ,'.Rear
Setbacc :SI',.,
Setbac :_
R!W Width
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Square Footage
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IILDING INFORM
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Number of Bedrooms
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DEPARTMENTAL REVIEW
I certify that 1 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.
Signature Date
Cond.
Approval
Hold
'd
Environmental Health Application if,'
���Approved
Ro m01 College
Room 200
I•a`
Planning/Zoning
N. 721 Jefferson
/
Engineers
N. 811 Jefferson —
Utilities
N.811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
ci
,
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that 1 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.
Signature Date
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Show on Site Plan:
Additional Information:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System s
Water Lines
Sewer Lines
Fences, Wells
Dnveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Landscaping
Drainage Plan
Hydrants
Topography
g1
Signage
Shorelines _
Highwater Mark
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