1986, 03-27 Permit App: 00010213 Addition(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
Owner's Name
LAST
Project Address (Street Name um Wi) ✓
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FIRST
MI
Zip
Applicant
Address
City
State
Zip
Phone
Business Phone
( )
Contractor/Agent
City l s
Address
t�fZarcc'e u't/
Architect/En neer
State
Zip
License Number (Required)
Phone
(S&9) cJaf-5 c
Business Phone
( ) 1l/etA-z-u
Address
City
State
Zip
Phone
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
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
Approved
CpApproval
Hold
Environmental Health Application #
3-a7—
W. 1101 College
Room 200
// 11114
r 1�1�
-
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
( Plan Review/Fire Prevention
N. 811 Jefferson
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S h$SELT To Fie f) Vg24 t= cftT-c.ci )
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: Additional Information:
Lot Dimensions
Landscaping
Existing Structures
Drainage Plan
Proposed Improvements
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 Description
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