1986, 06-09 Permit App: 00012201 Addition (THIS IS NOT A PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
COMPLETE IN INK
(Please return thi original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE
IProject Number
Owner's Name LAST FIRST MI
Project Addres (Street Name&Number) ` —Zip
/ 20). ( G 7f-c, (/1C),(-,
Applicant ddress '�
4//-e.-, E -7-46, „Ar / 2o x 1 6
City State Zip G, -- Phone -- - ---
/,,0 0 04 ,.,.,1— Le,4. r f 2d 6 5-o f ( el y) 3? 1 b
Business Phone
5'or• ( Q'LM 9 5fo
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
City i State Zip Phone
_ ( )
Contact Business Phone
( )
Lender
Address
City State Zip Phone
( )
Describe Work Res. Comm./
/ fl t-r i c iJ -T() VS r oEkdrG F08 _Attr y S HGP ✓
Subdivision/Plat Name! Plat Number
PPC- aV1T y
Assessor Parcel Number f Lot Block Plat Number
Pertinent File Numbers Zo e 1• 7 Comp.Plan Census Tract
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
I I
Front Setback Left Setback Right Setbact. Rear Setback R/W Width
Additional Information
I I Square Footage
r
z
.e 0
,, u.
z_
1; - z
'
z
,...v, .:.4,,,,,,,,42:,,,,2„.„ - 0
J_
m Number of Bedrooms
r Date Group Type
//� v0
•
DEPARTMENTAL REVIEW
Cond.
Approved Hold
Approval
Environmental HealthApplication N ('" - L,^'f 3 & ' *
W. 1101 College $/� /
Room 200ri( f", '� '� ,
i..4-(7/,' )" 111 L Li% / ,t,A iy.,•:4"4/7/.6 : , , al,,,, _,,,t,),%,,,,,,, ,,,,, ,
Planning/Zoning 6,-.1-44,
N.721 Jefferson Dew—,
lt‘o Aim t T(G4) e L.i L L it-t E�1rf" Avstc E EX:c.u,.4 r co-) 4-/-79-suIR-1z DS
P'r-/2- 4.dS . tot C> ( 7)
Engineers
❑ N.811 Jefferson ___I _
1
11••=111••••••11011111.1.111 .01111111Nik MIK JEW MMIMINIMMIN=IMMIIMIN 141•11111111111101
Utilities
❑ N.811 Jefferson
0/Plan Review/Fire Prevention
N.811 Jefferson r---
Other(SEPA/Critical Material/etc.)
El k---/ Il
CI 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.
"Z(....4..... e,
Signature v„//C ` `Date 5'
_
I I i
Show on Site Plan: Additional Information: ;
Lot Dimensions Landscaping , f
—_ +_
Existing Structures Drainage Plan
rt
Proposed Improvements Hydrants
Structure Setbacks Topography -k t1 f - +
Easements Lighting
Septic System(s) Signage ,t. } r
Water Lines Shorelines f� t {
Sewer Lines Highwater Mark T/4
z
Fences,Wells Cr"-
.
Driveway(s) immumi
--
Right of Way Width(s) j t.�C` ! �' I
Fronting Street \_) \-- ,,,i,,) N-A. "kg,
Flanking Street 11 Se Names of
i t5+ til
,
bri
Legal Description 3 i 6 .— —
,
,pr,.,
_ . _ , i , - 1- . .
T t )— . I
_ - , cx),__:__. _____, _
I
�t
i _ .\ �_ r _ _ �_ t L._
.: , , ...„ ,"
i
I\
,
of _ _ ..- - _-
_._� E
— - t __E I :
,
1 j
}� i - l_
t
.
r
7
Z IP
� tt5
t
-..--f.--_-,____
,
3 T-
A :.
5
t
r -r- + --2='—t 4a ,its
z
T
i
i i
1
to
L __
r -1 1 ___
IOr 1 a ' •
11 {
_" Qli}
rirAsti
a
EJ I iPC
—.1(:s17)— —11sia-- (7 • 441 I , 1
F�
,
-
i
i 3 t
QQ
..:: ,
, 1
Date ( —�— — . , 4
`= `— , -� - —
f
, i
1
, ,
Revisions: Attachments: 2 €�` ,Q !tl 1. __ _ i
I
C }I i II