1986, 03-18 Permit App: 00010087 Shop(THIS IS NO1 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
Project Number
/00
Owner's Name
LAST
FIRST
MI
Project Address (Street Name & Number)
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Applicant
•
City
•.a c, ki9 A/
State
C� /
Zip
Zip
Address
i/ o„ e
Phone
Contractor/Agent
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Jc
B
City
State
Contact
J' f) ,
Architect /Engineer
City
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(..s-c7)
(..s -C) .73 J .
Business Phone
(
Address
Zip
License Number (Required)
/9//,f1/ /
State
Zip
Phone
(•.5'-e ) Y-�� �` d
Business Phone
(
)
Address
City
Phone
Business Phone
(
Add ess
State
Zip
Phone
umber of Buttdings
Lot Size (Sq. Ft. /Acre)
Comp. Plan
Comm.
Plat Number
Census Tract
Right Set
Rear Setback
2(x,5
Frontages,
`75
R/W Width
Type
YN
DEPARTMENTAL. REVIEW
I certify that 1 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
Date �/ oe j, E;
Approved
Cond.
Approval
Hold
7 Environmental Health Application #
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W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
Pian Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that 1 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
Date �/ oe j, E;
Show on Site Plan: Additional
,
Info .._ _ .,��. •
Lot Dimensions
Landscaping
P 9
Existing+' --
Structures Drainage Plan
._ , �
PoctureSetbacks Topography w osed Improvements Hydrants
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,
s.
,
Easements Lighting
Septic System.: .x
(s)
Signage
s..
Water Lines Shorelines -
Sewer Lines Highwater Mar
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,
FencesWells �. ,.. - . � - . 7- i . • ,
t - �
Driveway(s)
_
K J � ,,.'_ Fes'.; 4 •.� 7
71
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Right of Way Width(s)
Names of ,
Fronting Street
i
Flanking Street
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Le al Descri tion _ _
141
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Date:
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Revisions: Attachments: