1986, 05-12 Permit App: 00010954 Addition (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)
SHADED AREAS ARE FOR DEPARTMENTAL USE 1ProjectNumber //ti45,/
Owner's Name LAST FIRST MI Cl f .
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Project Address(Street Name 8 Number) Zi
Applicant 7-
Address", ''
.47
/4 ler pier 6
City State s Zip Phon
Buess Pho
474/417'
.So 9 5
Contractor/Agent Address
el
City State Zip Phone
JP eft/ G off 7 ; ' ', . eQ
Contact License Number(Required) Busi ess Phone
Architect/Engineer Address Gv/T
City State Zip Phone
Contact Business Phone
Lender Address
City State Zip Phone
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�t �latNumber
�f rcel Number Lot Block Plat Number
av6411—*"' 21oUr
Peri � Ilumbers Zone Comp.Plan Census Tract
t pg Number of Buildings Lot Size q.Ft./Acre) Depth Frontage
IF
�" Lett Setback, Right Setback Rear Setback R/W Width
� i Square Footage
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= Number of-Bedrooms
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Group TYPO
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Show on Site Plan: Additional Information:
Lot Dimensions Landscaping
Existing Structures Drainage Plan — } -. - - - -t
Proposed Improvements Hydrants i t
Structure Setbacks Topography 1
Easements Lighting __ :_ t
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
Legal Description
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Scale:
Date: - - — —+----
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Revisions: Attachments: r
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DEPARTMENTAL REVIEW
ApproCond.
Approval Hold
/Environmental
`•HealthW1101 CollegeApplication# C D--
Room 200 �(J�
Planning/Zoning
❑ N.721 Jefferson -
Engineers
❑ N.811 Jefferson
Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention 6-IZ436
Q` N.811 Jefferson PQreai
Other(SEPA/Critical Material/etc.)
0
❑ 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.
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Signature -'lz'-':--. 'r Date = ift .t:
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