1985, 10-22 Permit App: 00008228 Addition (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 Aro)eNumber
Owner's Name LAST FIRST MI
Project Address(Street Name&Number) Zip
E Lf33( 204 AJa 91iI Z
Applicant Address
SU4M L At S Pt3o �E
City State Zip Phone
(424 ) 751s
Business Pho
( S' ) 1'0 11
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
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Subdivision/Plat Name Short Plat Number
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Assessor Parcel Number i of Block Plat Number
Pertinent File Numbers Comp.Plan Census Tract
Number of Dwelling Units NumberI tidings lot Size(Sq.Ft./Acre) s Depth Frontage l
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Front Setback `Left Right Setback Setback.,., R/W Width
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Additional information
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a. Number of Bedrooms
i T ician bate
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DEPARTMENTAL REVIEW
Approved Hold
Approval
NiEnvironmental Health Application# ,'
W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
XN.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.
Signatur �.� _ - Dat
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Show on Site Plan: Additional Information:
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•Lot Dimensions Landscaping , ;
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ffsting Structurils Drainage Plan ;
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Structure SetbaclaTopography 4 ; _1
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Water Lines\--4t Shorelines
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