1985, 08-29 Permit App: 00007181 Addiition(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
l-4
Peeress
5 7,52 i 7 --
Applicant
2ucL.q 74/ARIt4N
Project Number 7 f
Phone
•271
Contractor/Agent
CIty
State
Zip
Business Phone
1 1
Address
Phone
Contact
License Number (Rey red)
Architect/Engineer
City
State
Zip
Business Phone
( I
Address
Phone
Gty
State
Business Phone
Md ma
Zip
Pion
Shovhon Slte Plan
Additional'
Additional'ntion
-
P0,SFoR41-
r@I"sting Structures
Proposed Improvements`
StructureSethecks
Easements
Septic System (s) °
Water Lines P
Sewer Lines
Fences, Wells
Driveway(s)
Night of Way WIdth(s)
Names of
Fronting Street
Flanking Street
ITs -
DrainYgeP arra s'
.i(lydrehts• :" ^?
4 11'opograpriy f . n°F• .9
Xightlpg s^,:
Signaj4 " r 1
,Shorednps'=-{-*;�,
';Highv)aterMark `
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Legal Description
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a �F
ry '�
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Scale:
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Date:
Nevislons• • Attachments'
1.
DEPARTMENTAL REVIEW
1
Environmental Health
W. 1101 College
Room 200
Permit Number
Approved Cond.
gpproval
id
Hold
J
Planning/Zoning
0 N. 721 Jefferson
Engineers
0 N.811 Jefferson
Permit Number
Utilities
❑ N. 811 Jefferson
Plan Review/Fire Prevention
❑ N. 811 Jefferson
[/ V
Su31.t c7 To st?
Other (SEPA/Critical Material/etc.)
Fast Track/Speclal Inspection Information
Project Representative
Phone
Address
I certify that 1 have examined this application and state that the information contained In It and submitted
by me or my agent is true, correct, legal, and binding.
Owner's Signature C¢, /]f1J-
Date