1985, 08-30 Permit App: 00007247 Garage •
(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 , /
Project Number -72`r
Owner's Name LAST FIRST MI
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Project Address(Street Name&Number) Zip
Applicant /sAddress
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City !, JJ State Zip Phone
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Contractor/Agent Address
City State Zip Phone
Contact License Number(Required) Business Phone
Architect/Engineer Address
City State Zip Phone
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Contact Business Phone
Lender Address
City State Zip Phone
Describe Work Res./ Comm.
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number Lot Block Plat Number
Pertinent File Numbers Zone Comp.Plan Census Tract
AC: T7•4
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
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Front Setback Left Setback Right Setback Rear Setback
Additional Information
'Aif 174:. ei • � Square Footage
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Building Technician Date Group Type
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DEPARTMENTAL REVIEW
Approved Cond.
` (� pproval Hold
,rye/ Environmental Health Permit Number (O/ ! 9 'ft��
u W. 1101 College /2/I , ,t_. )�
Room 200
Planning/Zoning
❑ N.721 Jefferson
Permit Number
Engineers
❑ N.811 Jefferson
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 egal,and bindin
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Owner's Signature ". iY
Era Date
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Show on Site Plan: Additional Information:
Lot Dimensions Landscaping
Existing Structures Drainage Plan
Proposed Improvements Hydrants
Structure Setbacks Topography
Easements Lighting
Septic System(s) Signage
Water Lines Shorelines
Sewer Lines Highwater Mark
Fences Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
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Legal Description
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Date: , ,c:<---
Revisions: Attachments:
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