1985, 07-18 Permit App: 00006446 Addition r �
(THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS
SHADED AREAS
OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return this original and your building plans to the Department USE of Building and Safety)
ARE FOR DEPARTMENTAL
I Project Number644C-i
Owner's Name LAST FIRST MI
e a)
Project Address(Street Name&Number) Zip
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Applicant Address
Yoe/n7 I�46-e A D ft / ,CSX 7a • —7
City State Zip Phone r
/icGtra s4 9 9aO 7 (5 09) �� — �'ff‘3
Business Phone
( )
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State I Zip Phone
( )
Contact Business Phone
( )
Lender Address
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P.h o:n�ze Zip
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DEPARTMENTAL REVIEW
Approved CpApproval Hold
Environmental Health Permit Number aJ7 '• '
W.1101 College 1)
Room 200
Planning/Zoning
❑ N.721 Jefferson _
Engineers Permit Number
❑ 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,legal,and binding.
Owner's Signature Date
I
Site Plan: Additional Information:
ensions Landscaping
Structures Drainage Plan
d Improvements Hydrants I':---� ;_
eSetbacks Topography I j
nts Lighting
(stem(s) Signage
ines Shorelines El , , ,
Ines Highwater Mark '
.
Wells (111 w.
y(s)
Way Width(s)
f 0�.4fp
ig Street
ig Street :
;
)escription
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Attachments: