1985, 08-16 Permit App: 00006922 Garage(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
IProject Number %n9
Owner's Name
LAST
FIRST MI
Project Address (Sree Name &Number)
Applicant
\
City
R�Rt 41
If State
Zip
0,3
Zip
Address
Xl n/" / 0,Z C' J2�Q!
Phone
G Z 's;' 2 y
Business Phone
(4-o7) ��6
Contractor /Agent
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
Architect/Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
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 is true, correct, legal, and binding.
Owner's Signatu
Date
Approved
Cond.
Approval
Hold
/ Environmental Health Permit Number
Ce' i3/65
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Permit Number
MINIM
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Pian Review/Fire 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 is true, correct, legal, and binding.
Owner's Signatu
Date
Show on Site Pian: Additional Information
riupuaou rinpruvu'imub
nyurants
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
I Descri
Scale:
Date:
Revisions: Attachme