1985, 08-07 Permit App: 00006731 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
g/ eSS Aedi E
Project Address (Street Name & Number) Zip
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Applicant
Address
City
State
Zip
Phone
( )
Business Phone
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Contractor/Agent /Y // //yj
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Address Aa D . /.3aK (Z2.S'
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City
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State
642.
Zip
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Phone
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Conta
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License Number (Required)
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Business Phone
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Architect/ Engineer
Address
City
State
I Zip
1
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
( )
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DEPARTMENTAL REVIEW
.
06'
Approved
Cond.
proval
Hold
� I
/
Environmental Health Permit Number' `
(}
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W. 1101 College
Room 200
/<
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
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
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 Signature
Date Q /• S
Show on Site Plan:
Additional Information:
Lot Dimensions
Landscaping
Existing Structures
Drainage Pian
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
..�C � w
L 912
Scale:
Date:
Revisions: Attachments:_