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1986, 03-17 Permit App: 00010070 Garage(THIS IS NOT A 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) of fS2'-0sl) 4 ..rr..,.I-., r,ilLr,v 0,1vL r.,I r✓u r,r,r..•. L. nL wm (Project Number .. Owner's Name LAST FIRST MI bt /:50JO l/icki 5L 214)-e f Project Address (Street Name & Number) Zic /9‘i61_7 _zizve/ef% Applican /114 )t hods o.v Address e /9Oo 7, 94.e e /fit"... 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'. a•iv l°`,l -n• ""'rx'i':." .. ..=•r^ \ r - ": s':Fx,• a :x`4. t.n,. ?i -Oroup•,ir::.';•;«; f'Typoi'y {Y 4 4 f..; r YM.\.�'.'.'''. t.. `. 1� t.. ss�L Y .: .. r Environmental Health W. 1101 College Room 200 DEPARTMENTAL REVIEW Application # _d. Approved Cond. Approval Hold Planning/Zoning O N. 721 Jefferson Engineers 0 N. 811 Jefferson Utilities O N.811 Jefferson Plan Review/Fire Prevention O N. 811 Jefferson 0 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 to compile said application Is true and correct. Signature Date Show on Site Plan: Lot Dimensions Existing Structures Proposed Improvements Structure Setbacks Easements Septic System (s) Mater Lines Sewer Lines Fences, Wells Oriveway(s) Right of Way Width(s) Names of Fronting Street Flanking Street Additional Information: Landscaping Drainage Plan Hydrants Topography Lighting Signage Shorelines - Highwater Mark ; ' ! I • • ' 1,