1985, 09-18 Permit App: 00007225 Addition(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
Owner's Name
Project Address (Street Name & Num r)
-/ ;n
Applica
LAST
State
&Li
Zip
FIRST
/r -o .
Contractor/Agent
Address
Phone
Project Number 7525
Business Phone
( )
Zip
9.7 o/:,
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
Architect /Engineer
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
(
Zone 'l TII .
Lot Size (Sq. Ft. /Acre)
comp, Plan
Cereus Tract
Environmental Health
W. 1101 College
Room 200
DEPARTMENTAL REVIEW
Permit Number
Approved
Cond.
Approval
Hold
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
Permit Number
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.
d f�
-c"* Date ' J T
Owner's Signatu
Show on Site Plan:
Lot Dimensions
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
Legal Description
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Scale:
Date:
Revisions:
Attachments:
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