1985, 07-15 Permit App: 00006681 MH (THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND C6MPLETE 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 I
Project Number >
C_,,,
Owner's Name LAST FIRST MI
.P I 1 - ..4x(-e s .. N.T pc
Project Address(Street Name&Number) Zip
`) 1 N. S A -t.v1,jr6gi212-
Applicant
Address -71 s S . et r r r� 1 l
1=a✓�N:-es CSS _ A 11ev. cif , .re
City State Zip Phone (S-C3S ) `3V
4 ce 6
Business Phone
( )
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State I Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
(
Describe Work
Res. Comm.
tr.) `'{.nt3/—L' <.'.t t OF" +I" O ' L-:: P°tt. it—ie (Z x g:4/
Subdivision/Pat Name/Short Plat Number
cIIC:11t O 'rS d4
Assessor Parcel Number Lot Block Plat Number
E
s 5 t�
j' ` rti4 -' i "$
Pertinent File Numbers Zone Comp.Plan Census Tract
r‘4rr�: ,
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
t?jC 70
Front Setback Left Setback Right Setback Rear Setback
Additional Information Square Footage
w
co
I—
Z
w
2
I-
cc
a„
a
w
0
Building Technician Date Group Type
DEPARTMENTAL REVIEW
Approved Hold
,,,/
Approval
Environmental Health Permit Number O (30 �U
❑ W. 1101 College
Room 200 /rte,
ZW1.4-7/-0,
Planning/Zoning
❑ N.721 Jefferson _
Permit Number
Engineers
N.811 Jefferson
t.N4 T Pc`P`eg..c2 As c F faICMI��2 _�c Oz -ot,c
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
w
Show on Site Plan: Additional Information: i
Lot Dimensions Landscaping
Existing Structures Drainage Plan _
Proposed Improvements Hydrants -- -- - .- ._
Structure Setbacks Topography
Easements Lighting
Septic System(s) Signage .
Water Lines Shorelines
Sewer Lines Highwater Mark ,
Fences,Wells i
Driveway(s)
Right of Way Width(s)
Names of '. F__ , .
Fronting Street
Flanking Street
.
Legal Description
'/2 dF N '/2 of LCA i S
Block Is
{
i
•
{
!
-d)-- -Wm--
Scale:
Date:
Revisions: Attachments:
1
{ i
I i I
w �
I --I
f
1 i f
j tot
'1F
Coos I \1
0 SQ‘)A-ic. aNt,(
U
tOff
S�c:,vtit` w c(
\ I
0 •----7- ft\
4
—,„
— •—• """ .i.4:
----.::•- .'''‘-,!' : 70
•—____, ,
•••':".tif: Z•:,,-.;•'.;:".:4'7:2r.,,•_,-.4.-:"..... :;•;‘,;--,• ....-.
;:;;'.,_':i7;.0t,T.,:-,L.i.,Zi.;'=t.: ;.:t*-i:;i',s.--', . • .•
s.--,-!..:.- 1,7.,..,';.!:',.,:•.i•t,,,,‘.:C::,'.;.;", •... .-Y:1 -- —• ,' ---—
. •
.. .
:;•..7.-' :•:::•'...74. .•"• :,'•‘. I •
...1;.••-•.":".i.:.• - .
'—....7.-'..,;—••
'; .....'
...., -
-'... •
/
—- • , _IA
, .
II
: I
•
•....... •
.., , • ,_,
,.....,
G\\ jv
Ji (1
I
At %
ri
• .. _ . 1 . _. 1.__._.2. _.. __I 1?‘ 4
. --- i c, e ---,- :
, , I
ts%
1 ,
. , , • . . .. r - i •
I —. i.....1" %L.-,...., ..... ;-4
N.4
-
; ....„, i {• ••_)
-- .-.....,<,)4%L. --, 43N,...•< •
I I
I ,....)
1 _
,•
•• ----1- .
. -.
'7,.. ).., . 't i 1
I *^ 1 •
. • ti i.. '
I
'I-1 Nc_ l•• ., I
• I
•.
\7, ,..1_..i•,.. 1,..,, . , ,._.1, c I
.. '. I
I .
I ;
I • f •
I . !• 1
...
• ‘••• '0"2.,
't i.•
. '
.o•i
S-
'.,
: . ;• iIN
' . 3
- - -1 •• -. -
• ___
. . _ • i i ',
c` •/,'`
.s. •
... ..A (.....4
)•'). 1 \1 77— )-\, •
, I
, . ... e '
. ;