1986, 01-31 Permit App: 00009549 Demolitionr
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(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)
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Owner's Name ^ LAST FIRST MI'
Project Address (Street Name & Number) USN Zip
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Business Phone
Contractor/Agent
Address
City
State
Zip
Phone
Contact
License Number (Required)
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Business Phone
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Architect/Engineer
Address
City
State
Zip
Phone
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Contact
Business Phone
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Lender
Address
City
State
Zip
Phone
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Plat Number
Pertinent Pile Number* + 't -;-r rl ':r - `
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I BUILONa INFORMATION
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Number of.Berlrooma
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Group
Type
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Show on Site Plan:
Addl,Information.
Lot Dimensions
Landscaping
Existing Structures
Proposed Improvements
Drainage Plan
Hydrants
Structure Setbacks
Topography
Easements
Septic System (s)
Lighting
Signage
U
Water Lines
Shorelines
Sewer Lines
Fences, Wells
Driveway(s)
Highwater Mark
1111.11
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Righhewat of Way Wldth(s)
Names of
Fronting Street
Flanking
.
Street
Legal Description
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Date:
Revisions: Attachments:
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DEPARTMENTAL REVIEW
I certify that I have examined this application and state that the information contained in it and submitted
by me or my agent to compile said application is true and correct.
Signature Date
Approved
Cond.
Approval
Hold
Environmental Health Application it
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
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 to compile said application is true and correct.
Signature Date