1985, 08-16 Permit App: 00006916 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
I Project Number (�,9/
Owner's Name LAST FIRST MI �v 4�
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Project Address(Street Name&Number) r Zip
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Applicant Address
City State Zip Phone
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Address 5 )./ G ( ' f7- & c
Business Phone
( )
Contractor/Age nt Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State I Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
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DEPARTMENTAL REVIEW
Cond.
Approved1Approval Hold
Environmental Health Permit Number / ""
gi W. 1101 College J fi/"
Room 200 . t-/`-SS
Planning/Zoning
❑ N.721 Jefferson _
Engineers Permit Number
El N.811 Jefferson
Utilities
El N.
N.811 Jefferson
/'PlanRevlew/Ffre Prevention
N.811 Jefferson ?. .'1
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.
•9 / -? . '
Owner's Signature 1 '� ,/ - Date /6
Site Plan:
rasions
Structures
J Improvements
DSotbacks
its
Vstem (s)
Ines
Ines
Wells
Y(s)
WayWidth(s)
If
ig Street
Street
Additional In
Information:
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Landscaping
Drainage Plan
Hydrants
Topography
Lighting---
Signage
Shorelines
Highwater Mark
Li�LLig
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Description
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Attachments:—
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