1986, 06-16 Permit App: 00011988 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)
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Projeet Number
Owner's Name LAST FIRST MI
Project Address (Street Name & Number) Zip
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Applicant
L6U-?'I seSLi 1
Address
((SIc7 1�44IC
City
D&
State
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Zip
IZ 0.6
Phone
(S�.) Z7-3Jgv
Business Phone
( )
Contractor/Agent��
Add ess
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l o �w "C'i -t16 L � i �� -b—
t? $Ok 14 ( 6 2'-1
City
c�„ e.,`" �
State
tea
Zip
W 21
Phone
ea) 72'-7- 2D"2-
Contact
License Number (Required)
Business Phone
( )
Architect I Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
« Yyork '
8Se t.0e^-SGE
Res.
Comm.
IP at(V 0/Short Plat Number
AsseesorParcel Number
Is- t _ q o4
Lot
`_'
Block
c.c..
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
:ut t DwellingUnits
;':..
Number of Buildings
1
Lot Size (Sq. Ft./Acre)
Depth
Frontage
t Se back
Left Setback
3S'
Right Setback
t8!1
Rear Setback
R/W Width
Additional Information
BUILDING INFORMATION
Square Footage
U(; -- 141_
Number of Bedrooms
n
1 Date/////
Grou�j
DEPARTMENTAL REVIEW
1 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
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
6w—
Planning/Zoning
N. 721 Jefferson
Engineers g7
la
N. 811 Jefferson g/'�[-3 7 /
8Y
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Utilities utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
1 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
Legal Descri tion
I
i
I
Scale:
Date:
Revisions: Attachments:
Show on Site Plan:
Additional Information:
Lot Dimensions
Existing Structures
Proposed Improvements
Landscaping
Drainage Plan
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
Legal Descri tion
I
i
I
Scale:
Date:
Revisions: Attachments: