1986, 03-12 Permit App: 00010030 Addition(THIS IS NOT A 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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( Project Number
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Owners Name LAST FIRST MI
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Project Address (Street Name & Num.: r) 'Zip
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Applicant
Address
City
State
Zip
Phone
usiness Phone
( 1
Contractor/Agent
Address
City
State
Zip
Phone
l 1
Contact
License Number (Required)
Business Phone
( )
Architect/Engineer
Address
City
Slate
Zip
Phone
1 )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
1 )
Describe Work. •
R5/oEiva Abo
-
627/3)
Res.,......../
c/
Comm.
• Subdivision/ Plat Name/Short[�Plat Number /
/'I i SSS l O k) FILLS �.
Assessor Parcel Number
085 1/4/ — 0330
Lot
3
Block 44.
Plat Number
Pertinent File Numbers -
Zone /�A� ^^ CC
/"'1"C-Sa 8
Comp. Plan
Census Tract
Number of Dwelling Units
1
Number of Buildings
1
Lot Size (Sq. Ft./Acre)
1
Depth,Frontage
-8
Po
Front Setback .
Left Setback
Right Setback
RearSetback
RtW Width
Additional information
I BUILDING INFORMATION I
Square Footage
• 151e P:
Number of Bedrooms
/
Building Techn ion
Date,(-
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Type
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DEPARTMENTAL REVIEW
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Approved
Cond.
Approval
Hold
Environmental Health Application
W. 1101 College
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Planning/Zoning
721 Jefferson
N.
Engineers
N. 811 Jefferson
Utilities
N.811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Materlal/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.
Date
-540(
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Show on Site Plan:
Additional Information:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines'
Fences, Wells
Driveway(s)
Right ofWay Width(s)
Names of
Fronting Street
Flanking Street
Landscaping!
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
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Revisions: Attachments:
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