1986, 10-02 Permit App: 00013399 Garage (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 this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USE -
Project Number 3
Owner's Name r LAST I FIRST / •J
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Project Address( treet Name&Num r) Zip
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Applicant [Address
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State Zip Phone
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Business Phone _
Contractor/Ager), Address
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City State Zip Phone
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Contact License Number(Required) Business Phone
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Architect/Engineer -� "� Address
City State ( Zip Phone
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Contact Business Phone
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Lender
Address
City State Zip Phone
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Res. / Comm.
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AiriessorrPerceiNumber'``-: Lot Block Plat Number
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'ttibe(pweliing HnIts Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
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Left Setback Right Setback- Rear Setback R/W Width
Additional information -
Square Footage
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=ring Techn - Date
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DEPARTMENTAL REVIEW
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Approve iJAtprovaI Hold
Environmental Health Application# '/�7 V' / /;w
❑ W. 1101 College p.'
Room 200 I��
Planning/Zoning
O N.721 Jefferson
Engineers
0 N.811 Jefferson
Utilities
O N.811 Jefferson
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N.811Jefferson BJ CT Tb FFPEQ e00J.5
Other(SEPA/Critical Material/etc.)
o 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 compil said ap ication is true and correct.
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Signature G�'i� / - Date tile 6
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Show on Site Plan: Additional Information: I l 1t i l f T.
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Lot Dimensions Landscaping -
Existing Structures Drainage Plan - I __._ ..._;— ___ _..._.—_:___.__I i__
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Structure Setbacks Topography i j __-_- _t____.
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Septic System(s) Signage , -- i I
Water Lines Shorelines - !
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