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1987, 07-13 Permit App: 87002150 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 I Project Number Owner's Name LAST FIRST MI Project Address(Street Name&Number) Zip Applicant ] Address 7 )i, -P,Y1 t/2' L City j State kik.- A Zip Phone Business Phone ( ) Contractor/Agent Address City State Zip Phone ( ) Contact License Number(Required) Business Phone ( ) Architect/Engineer Address City State Zip Phone ( ) Contact Business Phone ( I Lender Address City I State Zip Phone - ( ) Describe Work Res. Comm. Subdivision/Plat Name/Short Plat Number - - PC,R ."\--Ct(Vi- Assessor Parcel Number Lot Block Plat Number .j-`. 44 \ 130 (7j _ • Pertinent File Numbers , ; Zone Comp.Plan Census Tract Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage Front Setback Left Setback Right Setback Rear Setback R/Wth i ---- C? Additional Information - - , Square Footage r'F, - - Z 0 F cc i��' ._ - __. u_ _ _— Z _ Z a J_ 5 m Number of Bedrooms Building Technician . n n Date Group T•, 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 Widths) Names of Fronting Street Flanking Street Additional Information: Landscaping Drainage Plan Hydrants Topography Lighting Signage Shorelines Highwater Mark Legal Description ,- 1 Scale• Date: Revisions: r Attachment%: 4 , ,t,___ _i : 4 . . _i_ ti L-- ----- , I -, ; , - _, 4 1 , , - . i...„..._ ... _ . - 1 • n Min 111111 IL; M i _ ._. t i , ill r- MM. -- -. II MEM 1 ... Ian ' fr I . : 11111 : , . UM MIMI irIIII mil ... .,. DEPARTMENTAL REVIEW Approved Cond. Approval Hold Environmental Health Application M W. 1101 College Room 200 Planning/Zoning N. 721 Jefferson Engineers N. 811 Jefferson . Utilities N. 811 Jefferson. I 1 _ . • ,. •..., .. Plan Revlew/FirePrevention) N. 811 Jefferson V rt Other (SEPA/Critieal Material/etc.) Fast Track/Special Inspection Information Project Representative Phone Address 1 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 3 MEM ME 111111111 1MEEi�op ■■ NL�IiN t ..� N1111�■■N NEE upo m 1111111111111111 IEEE ■■11!11■N!■■■ ■111!11■1 11■1111111111■■R# Ell ■■■■■.■■.1NN■■ 111,■ ■■■..■■■.■.■■■■�N■.. ■.....■Nr■. �il ! iN11 rim. AHEM ■1.=1111111111!■1!.11 MEE�"■1 �■ 1111l111■1!■'I' ■ �■■ �■ ■■■■..u.. ■. uiiiniiil mi Illllluiuuuuii ■■■.■■.■. =A lE;177■.■■ ■■■■■■NNN■ N"""�' ■1 ! 1111111■ mumm ■■■■ ■■■■ ■■■ i. _ r�■ ■■■■■■■■■■■NN■■ /1111111 __II �ili11111111! i�r�l w■..■■■�■�■N■IL��■■■■■■■■■ NNN■■■ ■111!11.1 ■1�■■1!1!111.11■M■! ■111!11■1 ■1�■l1111111■11■■■! 1 4411 Mit