1986, 04-10 Permit App: 00010408 AdditionrZS3( -Gz-jt
e (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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City
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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 to compile said application is true and correct.
Signature
Date 41 - 406--
Approve
Cond.
Hold
• Environmental Health Application # II
CApproval
i V
.'
W. 1101 College
Room 200 •♦
9 t
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/Flre Prevention
N. 811 Jefferson _
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 41 - 406--
I
Show on Site Plan: Additional Information:
Lot Dimensions Landscaping
Existing Structures Drainage Plan
Proposed Improvements Hydrants
Structu re 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 ,
I