1986, 12-16 Permit App: 00014548 Garage(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)
Owner's Name
SHADED AREAS ARE FOR DEPARTMENTAL USE
LAST
(dcre
riin rFtBST I
IProject Number
Project Address (Street Name & Number)
Applicant
f('-
CC
Address
Zip
City _
0 ,
State
Zip
2.,
Phone
Business Phone
1 )
Contractor/Agent
/7 State
City
Address
Zip
Phone
Contact
Architect! Engineer
License Number (Required)
Business Phone
t )
Address
City
State
p
Phone
(
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
Describe Work
t -f- 4C fi)
Subdivision/ PIa;Namel$hort Plat Number
c A( -C3% X36)
I + --I1/4JT CjC.X1 t, ORC 144-Zo
Res.
Comm.
Assessor Parcel Number
oss
Lot
Block
Plat Number
Pertinent File Numbers
Zon
t
Comp. Plan
Census Tract
Number of Dwelling Units'
Front Setback
Number of Buildings
Left Setback
Lot Size (Sq. Ft./Acre)
Right Setback
Depth
Rear Setback
5
Additional Information
DEPARTMENT USE
Environmental Health
W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Permit Number
Approve
Cond.
Approval
Hold
Planning/Zoning
❑ N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
Permit Number
Utilities
❑ N. 811 Jefferson
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
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
eXC, W i 28 P7
Legal Description
S !LIUFT
eXC, W i 28 P7
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