1985, 08-15 Permit App: 00006982 Residence (THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND T
COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE 1 �
Project Number
Owner's Name LAST FIRST MI
/L- S
Project Address(Street 7Name&Number) Zip
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Applicant Address
-. 79771 �-
City State Zip Phone
( )
Business Phone
( )
Contractor/Agent Address
li!tt , _4,(40 &c 11 J r6''/fe'X life,cri/
City State a.//,s., Zip Phone
<-,. c�,'"-tie/co_ /, f1 /V ( s7,7)R 27 �,°Qv
Contact License Number(Required) Business Phone
/tre .tel e rrt it '4 S,i S 'SVS-7)1a- ( ) j.22 — 0 7d.-2____
Architect/Engineer Address
City State I Zip Phone
I ( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
Describe Work Res. Comm.
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/2 i'/. r.rte'c`F _ -
Subdivision/Plat Name/Short Plat Number 7 r
!-/-r7/"C/i.._. 7/'i< ! i 1`2/>/,'//`lt'4--''
Assessor Parcel Number Lot Block Plat Number
_., v _. i .t :-.f / y 57
Pertinent File Numbers Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) I Depth Frontage
Front Setback Left SetbackRight Setback Rear Setback
.3_,--,,._________________y__;______."- ,
.____e,:_L_______gt:____________ ___.
Additional Information Square Footage
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1-
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Building Technician Date `�— Group Type
.
DEPARTMENTAL REVIEW
Cond.
Approved Hold
Approval
Environmental Health Permit Number
❑ W. 1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson _
Engineers Permit Number
v/
N.811 Jefferson e�-2 \Sv(VJ�
Utilities ` .^_ n V) I
N.811 Jefferson Ia-kUp� (1.,....4k. ck
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Plan Review/Fire Prevention?4
���yo
N.811 Jefferson i/'
Other(SEPA/Critical Material/etc.)
❑ Dc,-;:----
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❑ 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: 1 { ! `�`� 1 1 {
Lot Dimensions Landscaping
P 9Ill I
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{Existing Structures Drainage Plan - � � � I � �--- �- -- -- --- -----
Proposed Improvements Hydrants -- j.
Structure Setbacks Topography I _
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Easements Lighting ----
Septic System(s) SignageffjIIIIIIMIIIIIII _
Water Lines Shorelines
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Sewer Lines Highwater Mark
Fences,Wells MIIIIIIIIIIIIIIIIIIMMIMIII
Driveway(s) II
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Right of WayWidth(s) --
Names of , �_
FrontingStreet {
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FlankingStreet ._
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Legal Description {
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Date:
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Revisions: Attachments: I 1 1 I
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