1985, 08-30 Permit App: 00007390 Relocate Residence(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)
OrIMI.JCI-1 Mr1 /YJ MI -1C Fl -Ill L/CrMrl I IVICIV I ML VJC
Project Number 470
Owne ' f e LAST FIRST MI
:,Amr / e v
• oject Address (Street Name & Number) Zip
E . t.. "2,a(Laaic),-� 43.v
Applicant
1°A (IL 81qE. l r/7/R 0,7-
Address
Asa 3 Nf LY(Vcam/o04
City
,5'100
State
-Lola
Zip
9_a 0 r
Phone
( I 3 a? - I,(//
Business Phone
( ) s1} ✓kr
Contractor/Agent
Address
City
State
Zip
Phone
l )
Contact
License Number (Required)
Business Phone
( )
Architect /Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
l i
Describe
yy�Work
gC.c—i:::^ fa"lC=_ A1L'_—i= (;C t vN/ Cj� ( 3 :' c . T5
Res.
Comm.
Subdivision/ Piat•Name/Short Plat Number
# __
Assessor Parcel Number
>:')C( �a --z_ _ 5ts5 13c >
Lot
4
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
i
Number of Buildings
L
Lot Size (Sq. Ft. (Acre)
Depth
Ci , ,
Frontage
't 1 &j
Front Setback
Left Setback
Right Setback
Rear Setback
Additional Information
DEPARTMENT USE
Square Footage
41e) \) CI 0 V. tom. ()-. .- a - .-i K.)'.tfacaK.
Building Technician
Date
GroupType
YPe
DEPARTMENTAL REVIEW
I certify that hae examined this application and state that the information contained in it and submitted
by me or my aigent i true correct I, and binding.
Owner's Signature
Dat
O7iq
Approved
Cond.
Approval
Hold
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1 Environmental Health Permit Number _ /� O/yJ•!
m1101 College t4(l It 77 / Jc 4
RoWom i/'� � L � 1T
Room 200
1
771 de % ' ' / 4212g -di V. , 4.44-464 •
n' -
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers ��,n
. N. 811 Jefferson i
-I/'
/, ,..ua�
Utilities
N. 811 Jefferson
I
Pian Review/Fire Prevention
N. 811 Jefferson
TY
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that hae examined this application and state that the information contained in it and submitted
by me or my aigent i true correct I, and binding.
Owner's Signature
Dat
O7iq
Legal Description
Scale: 1
Date: r b,r,1
Revisions•
Attachments:
i
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 of Way Width(s)
Names of
Fronting Street
Flanking Street
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
Scale: 1
Date: r b,r,1
Revisions•
Attachments:
i
L o T
r
C IY) 47\ j , 7