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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) 011P1 LIC -1...., P11-11-,10 /1,1- UVn LiL_r Pin i Ivi C IV I /1L LJJG Projeet Number Owner's Name LAST FIRST MI Project Address (Street Name & Number) Zip .S4- -i v�€,lLS52� cli°.4. `.. Applicant L6U-?'I seSLi 1 Address ((SIc7 1�44IC City D& State e.,) Zip IZ 0.6 Phone (S�.) Z7-3Jgv Business Phone ( ) Contractor/Agent�� Add ess C`7 i 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 e --- 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: