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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 I i ■■■■■I..■■ ■■■ IIIIIIIIPJII1MM m i■ ■u■ MR Eriii■i■■ dE ns ii �■ 11111Pargr i AIL mME 11 :plippillaall n + _ k .I ■■slims MOs1I;1ol■■WOJEY iIIIiii • ■. H iail: Immo ■■■n■mommouNSE ■■■■■MEM • ■ ,\ . :■■s �'i:::P'r't ■■■w�A : �i iiIi'r NM ■1 • 111111 _J__ _ __ _- as • ICI Health 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