1986, 09-30 Permit App: 00013368 Garage i
(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
' Project Number
Own ame LAST FIRST MI
Proj Address(Street Name&Number)r)7'' Zip
Applicant Address
i City State Zip Phone
57)0 A-'6_ u)4 , 9 9az / (cccl) 5-3y--9 7?
6' Business Phone ki/C
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Contractor/Agent I 1 Address
City State Zip Phone •
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Contact License Number(Required) Business Phone
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Architect/Engineer Address
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City State Zip Phone
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Contact Business Phone
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Lender
Address
City StateZip Phone
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•`•ivision/Plat Name/Short Plat Number
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Inent File Numbers Zone Comp.Plan Census Tract
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Lot Dimensions Landscaping
Existing Structures Drainage Plan T --t-
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Structure Setbacks Topography
Easements Lighting ~ +- ., -- ___ ` __ —
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Water Lines Shorelines '
Sewer Lines Highwater Markf—
Fences,Wells 1 i i i '
Driveway(s)
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Flanking Street
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DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application#tcr—
41,
m W.1101 College lP O
Room 200 ,,i� I gat
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
0
❑ 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