1986, 08-11 Permit App: 00012572 SidingrCl3_071p
(THIS IS NOTA PERMIT) •
E.
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
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Owner's Name LAST H^ FIRS My,�
Project Address (Street Name & Number)r)p,�%% � /J�� �\\ _�y�J Zip
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Applicant
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Addr
1/457 : / /
City
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State
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Zip 9,7-_,0
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Phone ( ) O J
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Business Phone
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Contractor/Agent
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Add
ass
77 -(9,70 lo 0-tll._..,.. r
City
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State
Zip
99ai07
Phone
4
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Con
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License Number (Required)
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Business Phone
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OArchitect/Engineer
City
State
Zip
Phone
Contact
Business Phone
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Address
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Zip
Phone
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Lot
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Block
Plat Number
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Zone
Comp. Plan
Census Tract
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Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
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Le{t Setback
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Right Setback
Rear Setback
R/WWidth
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Square Footage
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Number of Bedrooms
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tllType
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Date
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'Group
Show on Site Pian:
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
Altai Information:
La ping
Drainage Pian
Hydrants.
Topography
Lighting
Signage
5horplInes
HighwateY Mark
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Legal Description
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Scale:
Date:
Revisions:
Attachments:
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• •
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health
❑ W. 1101 College
Room 200
Application #
Planning/Zoning
O N. 721 Jefferson
Engineers
O N. 811 Jefferson
Utilities
O N. 811 Jefferson
Plan Review/Fire Prevention
O N. 811 Jefferson
Other (SEPA/CrItical Material/etc.)
O Fast Track/Speclal 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