1986, 07-14 Permit App: 00012103 Garage (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
Owner's Name LAST FIRST MI
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Project Address(Street ame 8,Number) Zip
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Applicant Address
City State Zip Phone
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Business Phone
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Contractor/Agent Address
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City State Zip
Phone
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Contact License Number(Required) Business Phone
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i Architect/Engineer Address
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City ‘ State Zip Phone
( )
Contact Business Phone
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Lender Address
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City State Zip Phone
( )
Describe Work ,,.... Comm.
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Subdivision/Plat Name/Short Plat Number
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Assessor Parcel Number Lot Block Plat Number.
2-1/5'3/ — 2-1/3 2(/-36-3i g
Pertinent File Numbers Zone Comp.Plan Census Tract
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Number of Dwelling Units Number of Buildings Lot Size Sq.Ft./Acre) Depth Frontage
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Front Setback Left Setback Right Setback Rear Setback R/W Width
Additional Information Square Footage
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m Number of Bedrooms
Building Technician Date GroupType
DEPARTMENTAL REVIEW
Cond.
Approved Hold
Approval
Environmental Health Application I ( Cf 1 )--------- ���' i
W.1101 College i
Room 200 /410. 4 -
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities I
❑ 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.
Signatura �� Date r-— 1 Ccf^ G
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Show on Site Plan: Additional Information: i I I { I I ( I r.. 1 -I 1 1
Lot Dimensions Landscaping I i I ! I i _A 1
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Structures Drainage Plan { I -- I I ! } 1 1 # _' 1--
Existing
Proposed Improvements Hydrants - i I , i _ I `.! j
Structure Setbacks Topography ' } a I ( I f + C I { 1
Easements Lighting + - i -- I { I
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Septic System(s) Signage —} -!.— ..L i__ I C i I I - { ... -�-- {
Water Lines Shorelines
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Fences,Wells ! ' 1 { I i _ I I t I {----
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Right Of WayWidths r i
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Names of
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Revisions: Attachments:
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