1985, 11-05 Permit App: 00008510 Garage (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
I Project Number 76/
Owner's Name LAST FIRST MI
A4-�.. /.an < fil,cRAPL G.-
Project Address(Street Name&Number) Zip
t/Z52 3 54yi e5/ GJ72 / 6
Applicant Address
/Vie/,/,4 e Z Ade 71 �/2�2 3 Sk y vi e
City State Zip Phone
(,Jac ( ) 12G y 6G t-
Business Phone
( )
Contractor/Agent Address
5a,
City State Zip Phone
( )
—
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
(
� � ;, ? a _ { a k;, .. ), Comm.
477/r Y {
ivisu /Plat i,Shai t 4
i i View` . 4 b z BIOGc Plat Number
Air f c i Nutril
1 i it/3i
otroliketi#116i4uNktjet5 Comp.Plan Census Tract
Millibar Of f Dwelling units NumberBuildit e ( q Et/Acre) Deptht �Yf�ry/� y� Frontage
es.
the ,; i g. it Setback R/W Width
kir ;i i ; S C ] k ' t
3 °
tittn�information Square F+ e()
i/i
0
Q
Z
8 r
U.
z
0
;' a
jm Number of Bedrooms
Building Technician to Group Type
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application# ATM-
W.1101 College
Room 200 6EC'JE
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities I
❑ N.811 Jefferson
Plan Review/Fire Prevention
0 N.811 Jefferson
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.
Signature/ 44'1.---' Date /1/;75r/ �s
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Show on Site Plan: Additional Information: I I
Lot Dimensions Landscaping
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Existing Structures Drainage Plan MIIIIMINIIIIIIMMIIIN■■. I 1111111111 I t
Proposed Improvements Hydrants ■� ■� ■�'� f
Structure Setbacks Topography
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Easements Lighting �...�..�.....�.�....�... �. ..�•.. _ IMItillingli=�.. - �- ( -
Septic System(s) Signage ■■-■������� J I
Water Lines Shorelines I 1ii■■ ■ ! ( !
Sewer Lines Highwater MarkMillI -.- I
Fences,Wells 1111( I }
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Driveway(s) I I
Right of Way Width(s) 1 - ; 111 ,
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Names of I I I
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