1986, 04-01 Permit App: 00010271 Addition _T
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(THIS IS
BUILDING PERMIT APPLICATIONNOTAPERMIT)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 r s r
Owner's Name LAST FIRST MI
fin
MAN / RR
Project Address(Street Name&Number) Zip
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Applicant a Address
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City State Zip phone
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Business Phone
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Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
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Architect/Engineer 'Address
1 City State Zip Phone
( )
Contact Business Phone
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Lender Address
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1 City State Zip Phone
( )
641
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DEPARTMENTAL REVIEW
Approved Cord.Approval Hold
Environmental Health Application# f2 5/ N4,44,
ig W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
•
Engineers
❑ N.811 Jefferson
Utilities
0 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
_ 1
Show on Site Plan: Additional Information: t
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Lot Dimensions Landscaping ai , [[
Existing Structures Drainage Plan 1 ; , . ( r. .___
Proposed Improvements Hydrants a __ } _ .; ._._
Structure Setbacks Topography ___ __ , '� ( ; I
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Easements Lighting �� �' { _ _ �. _ �„ 41
Septic System(s) Signage
Water Lines Shorelines �� j
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Sewer Lines Highwater Mark _-__ . _ -__ , -- _
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Fences,Wells E 1 t.
Driveway(s) } �
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Right of Way Width(s) , ,
Names of < ` ,
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Fronting Street II
Flanking Street -- 16 t1 -- f- I- '- -
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Legal Description
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Revisions: Attachments: 1 j 1 _
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