1986, 07-22 Permit App: 00012237 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)
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Project Number
Owner's Name LAST FIRST MI
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Project Address (St _ t Name & Number) Zip
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Applicant
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Address
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City
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State
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Zip
eigzty
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Phone
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Business Phone
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Contractor/Agent
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
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Architect/Engineer
Address
City
State
Zip
Phone
( I
Contact
Business Phone
( I
Lender
Address
City
State
Zip
Phone
( )
Describe Work t t
Res.
Comm.
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number
Lot
Block
Plat Number
Pertinent Fiie Numbers
Zone��
Comp. Plan
Census Tract
tlumberof Dwelling Units
Number of Buildings
d
Lot Size (Sq. Ft./Acre)
Depth
r
Frontage
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forst Setback
Left Setback --, v L' +-1-4 s
Right Setback
Rear Setback.._.:...,. .
R/ W Width
it anal information
BUILDING INFORMATION
Square Footage ..
Number of Bedrooms
tiling Technician.-,, Date
Group
Type
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
Cond.
Approval
Hold
e Environmental Health Application # 0
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W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
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Engineers
N. 811 Jefferson �� ���
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Utilities
N. 811 Jefferson
Plan Review/Fire Prevention
N. 811 Jefferson
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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
0W 0r; Site Ilan:
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
Z
Scale:
Date:
Revisions:
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