1985, 08-05 Permit App: 00006674 Enclose Patio(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
Protect Number
Owner's Name
tee.
LAST
FIRST
-e, •
MI
D
eSa
Pro ect Address (Street Name 8 Number)
Zip
Er
Contractor/Agent
City
State
Contact
Business Phone
Address
Zip
License Number (Required)
Archltect/Engineer
City
State
Zip
Phone
Business Phone
)
Address
Contact
Lender
City
State
Phone
Business Phone
Address
Zip
Phone
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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CI 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/Crltieal Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
I certify that I have examined thls 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