1986, 07-25 Permit App: 00012343 Residence (THIS IS NOT A PERMIT':
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSEPARTS 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 j 5� p
Owner's
LAST FIRST" MI f
Project Address(Street Name&Number) Zip
I\l . 1017 t'SG14112..GE -( C
Applicant Address
13ZUCG !AtLi>A- / 7Etzrz.t Skc & 14, 4135 Fair
City ,,..„ State — —
ZIP Phone
S OrdAa4Ls WA- gg02:1 ( SOy) X1'28-1Z46
Business Phone
( )
Contractor/Agent Address
6A-1.4E- A- Azov c
City State Zip Phone
( 1
Contact License Number(Required) Business Phone •
14l( P/ -G 7- --7/, r -, ( )
Architectlit'gineer ' . p /O.�p)6 Address
O I/ 4 V • _
City State Zip Phone
( ) •
Contact Business Phone
( )
Lender Address
' City State Zip Phone
(
Describe Work --
Yt ( 0 -�NCE Res. Comm_
Subdivision/Plat Name/Short Plat Number
'_ 'P( T10
Assessor Parcel Number Lot Block Plat Number
.3302 G 1
Pertinent File Numbers Zone Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth i Frontage
i
Front Setbaojc , Left Setback )_ „{. Right Setback I Rear Setback R/W Width
z.- e.) '
Additional Information
r ,_ Square Footage
.: _sad
U.
°
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Z
s
i a _ m Number of Bedrooms
€ li in Technician
- 4 Date
Group TypeT,, .' 'r^ i
v a ^ . � r ie'
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DEPARTMENTAL REVIEW
Cond.
rg Q��� Approved Hold
Approval
Environmental Health Application# '/ )g.—
erh
W.1101 College
1
7 ,/
Room 200 <
Planning/Zoning
D N.721 Jefferson
Engineers ��yc� //. �y Acr .j"
N.811 Jefferson "TLwa 4`'',o-/
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ 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,spoiltion is true and correct.
SignatureA.'d
Ade�1j/ --: Date 7-25--56,
Show on Site Plan: Additional Information: _ I i ___:__ __ .- _ -- -- -- ---- --
•
•
imensions Landscaping ( 1 • _• I _ •' - -- + I — , ---T--.--J.-&-' • - -—- -- , {
ExisLotting Structures Drainage Plan i f a-o' io=o" y o°a I I t3Zbe' N e�`� •
i 1 ' I a I oI e ' e , N
Proposed Improvements Hydrants } _ ;
Topographye e • • ~ N le + - A - •
Structure Setbacks i« N �f _: , NI i t T ' 7 ! 1 i `'° �___1 <-r,- r h : i
Easements Lighting I » i ° ( ~ ( ~ - ± I h �! --- --,- - — _.
Septic System(s) Signage I '_____,____--4.---jt r I 1 f i
Shorelines i i i i ( ; , , — 1 —` - -- _ —
•
Water Lines I j ---- —' r •I 1 -,---f---2��
Sewer Lines Highwater Mark —._ i - _ ,. —_ ` - �- , I i t - •1
Fences,Wells — i �- , } } • I •
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Driveway(s) •
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Right of Way Widths) —— --- —#=-- - �`-a� - — -=—; I i '15 I _ • -
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Names of - — — --r--r:., -.
Fronting Street _ .- — T - ---- I- -- ' i i
Flanking Street __ ••
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Legal Description —___ ` — - - — "" <4i.
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Revisions. • Attachments: ; --'- • j I 1 i EMI 'µ x • _ ,�
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