1985, 10-03 Permit App: 00007991 ResidenceOff
(THIS IS NOT A. PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this uriginal 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
'etc A,
7614't
Project Address (Street Name & Number)
E. /83) ;N,/Cd f,.;4ac...Q s (' C��
lAddress
Applicant
City
State
Zip
Phone
Zip
(Scf) 22-ol44
Business Phone
( 509) X34 - h2C I
Contractor/Agent
SR 1-11E
Address
City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
Architect/Engineer
Address
City
State
Zip
Contact
Phone
1
Business Phone
Lender
/WJE
Address
City
State
Zip
1 Phone
Pow
Comm.
SubdivlsloniflaNemelShort Plat Number
( 2 N PrC (2.(C,.,f T lb<v —Of S z Mk C ---C
Assessor Parcel Number
0-155)-r01f3
Pertinent File Numbers
Lot
Block
Plat Number
(Z4
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
,163 A,
Depth
33\
Frontage
(oo
FfOnt Setbactk
Left Setback
ht;Setback_
Rear Setback
Building Technician
Date
463
DEPARTMENT USE
Square Footage.
Group
R 3
T
DEPARTMENTAL REVIEW
I certify that I have examined this application and state that the information contained in it and submitted
by me or my a. • • t is true, correct, legal, and binding.
Owner's Signature,
Date /Y r--3435
Approved
Cond.
Approval Hold
�
Environmental Health Permit Number i 616--'
7
/ifi&
1101W. College
Ro
Roomm200
Planning/Zoning
N. 721 Jefferson
c C n 2s - g---;
Permit Number
8 o
y=el'ir
N. 811 Jefferson 3NA 1647 r�,—/037
Utilities
N. 811 Jefferson
I
jIyf::I
/ Pian Review/Fire Prevention
N. 811 Jefferson
Other (SEPA/ Critical Material/etc.)
"....K
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 a. • • t is true, correct, legal, and binding.
Owner's Signature,
Date /Y r--3435
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
Scale.
Date:
Revisions:
Attachments:
Legal Description
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Scale.
Date:
Revisions:
Attachments:
PROFESSIONAL LAND SURVEYORS
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