1985, 08-23 Permit App: 00007068 Solarium(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
IProject Number
Owner's Name
LAST FIRST MI
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Project Address (Street Name & Number) /
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27/C) yZ S ct vz d o /1
Applicant
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Address
Zip
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City
State
Zip
Phone c�
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Business Phone
Contractor/Agent
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
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Architect/Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Add ess
City
State
I
Zip
Phone
SubdiviSbnlAat Nat a/Short Ptat'Number
-)CAIDE PoS
Comm.
Assessor Parcel Number
Lot
11
Block
Plat Number
Pertinent File Numbers
Zone a su C%
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage •
Front Setback
Left Setback
Right Setback
Rear Setback
DEPARTMENT USE
Building Technician�
Ma-4)
Date
Group
, Type
DEPARTMENTAL REVIEW
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
,e
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Approved
Cond.
Approval
Hold
`
/Environmental Health Permit Number
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W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
I
Plan Review/Fire Prevention
N. 811 Jefferson
.
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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
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U1111o11blulla.
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Scale: ° s
Date:
Revisions: Attachments:
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Scale: ° s
Date:
Revisions: Attachments: