1985, 11-13 Permit App: 00008678 MH(THIS IS NOT A PERMIT)
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)
Show on Site Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Scale:
Date:
Revisions:
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
N
Environmental Health
W. 1101 College
Room 200 _
tQr(:50
Planning/Zoning
[:] N. 721 Jefferson
Engineers
ElN. 811 Jefferson
Utilities
❑ N. 811 Jefferson
Plan Review/ Fire Prevention
❑ N. 811 Jefferson
Other (SEPA/Critical Material/etc.)
DEPARTMENTAL REVIEW
Application ff
O'er C�- I C C5 Y f -F -h f")
Cord.
Approved I A, n'...l I Hold
❑ 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.
Date