1986, 01-31 Permit App: 00009288 Residence TM X30 ,
(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 �R
I Project Number y2 CJ
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Owner's Name LAST FIRST MI E/
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Project Address(Street Name&Number) Zip
/ 7 0 600(77f Q40cl�y ,/d66-. 9Y1/2-
Applicant Address
Gni` . -C 9E 4 64 ocitf77S" /�� / • ,d>< /l®g'y
City State Zip ` Phone
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Business Phone
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)9 _ 07J" 2_Contractor/Agent Address
City State Zip Phone
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Contact
/ License Number(Required) Business Phone
/ it Z g- i t'4-'✓4 S el c -a t/J 6 ( ) 91 L - 0 7,1- 2---
Architect/
,_._.Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( 1
¢ Res. Comm.
Describe Workw•`5 n ..,',:l."..4.:,‘ ° � - r r & 4gM
Subdivision/Plat Name/Short Plat NumberrtiQk�4
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Assessor Parcel Number Lot Block Plat Number
Pertinent File Numbers Zone(--
one } Comp.Plan Census Tract
- t-
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
/ / /`/C' 7 .
Front Setback l Left Setback Right Setback I Rear Setback '-R
Additional Information Square Footage
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tr/� TS1.37 '/- Y
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Building Technician Date . .., Group Type
Show on Site Plan: Additional Information: '
Lot Dimensions Landscaping ' j r
+ _�_ Tom_
Improvementsy g --_- - _. i I i i — t �
ExistingStructures Drainage Plan
Proposed Hydrants l 1
Structure Setbacks Topography i
_ _ ._
Easements Lighting __ — /--- }
Septic System(s) Signage , . - .. ;
Water Lines Shorelines
Sewer Lines Highwater Mark T ---_ + }--_- -___- . ;
Fences,Wells -+ - - ----- —' — -+ -- --
Driveway(s) 1
Right of Way Width(s) a }
Names of
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Fronting Street
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Flanking Street -r
A.
Legal Description
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Scale:
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Date:
Revisions: Attachments:
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Permit Number �/�
El w. 1101 College
Room 200 Et OE SEct EI
Planning/Zoning
❑ N.721 Jefferson
Permit Number /A _ 4
Engineers „/
N.811 Jefferson A/'” '447 --
,Al*
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Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention i
❑ N.811 Jefferson --- b
7:01,. C1
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,correc legal,and binding.
Owner's Sign re c_Ze. _ c `,,,-=- ="—'' _Date _4L�/ _
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