1985, 07-19 Permit App: 00006503 Garage 0 l
(THIS IS NOTA PERMIT) ! �`
BUILDING PERMIT APPLICATION WORKSHEET f
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
MPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
Project Number
Owner's Name LAST FIRST L
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Project Address(Street Name&Number) Zip
Applicant Address
City State Zip Phone
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DEPARTMENTAL REVIEW
Approved Hold
Approval
Environmental Health Permit Number '%
❑ W. 1101 College O
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Room 200
/tido AC2-(A;(4-1)
Planning/Zoning
❑ N.721 Jefferson
Engineers Permit Number
❑ N.811 Jefferson
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
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Show on Site Plan: Additional Information: I 1 1 _
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Lot Dimensions LandscapingMIIIIII 111111 ,1 I I I I
Existing Structures Drainage Plan INNINIMMIIIIMI11111111111111 EMI.
Proposed Improvements Hydrants
Structure Setbacks Topography
Easements Lighting _ IIMIMIIEIIIIIIIIIIIIIII IIIIIII a 111 � _ , : ' _,
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Septic System(s) Signage
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Water Lines Shorelines ■
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Sewer Lines Highwater Mark I } # j _..__..
Fences,Wells - III I
Driveway(s)
Right of Way Width(s) I .
Names of
Fronting Street tiI _
Flanking Street
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Legal Description4'9
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Revisions: Attachments: � � I I � � � � � I � � `� � 1 � -__; . 1.._.—r__.:_. I _..[__�.—.
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