1985, 10-11 Permit App: 00007992 Addition (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 rprolect Number ,igt/2, ,.
Ow r' Name LAST FIRST MI
oject Address(Street Name&Number)
Zip
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Applicant,/
/ Address
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Business Phone
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Contractoll/A.ent /"�1 Address
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City State Zip Phone
Contact License Number(Required) Business Phony (7,,.f
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Architect/Engineer Address
City State Zip Phone
Contact Business Phone
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Lender
Address
City State I Zip Phone
Describe Work ,
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Subdivision/Plat NameiShort Plat Number
Assessor Parcel(!umber Lot .. Block N
Plat umber
51/3 .. QOM
Pertinent File Numbers
' f�mp. ...
Number of Dwelling Unite ! Number of Buildings " tet ESze igq, /Acre) Depth Frontage
Front Setback Leif Setback `Right Setback Rear"tetiaok, x FtIW Width
Additional Information ° , e .
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m: Number of.Bedrooms `
Building Technician Date
. 'Group .. `x" .. Type
DEPARTMENTAL REVIEW
Approved Cond. Hold
Approval
a Environmental Health Application# V )
1 W. 1101 College `o_„_g5
Room 200
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A,,,�i.. PIC• T„„e, t7 O s.2/1
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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.)
❑ .
❑ Fast Track/Special Inspection Information
Project Representative Phone
Address
I certify that I have examin-d this -..lication and state that the information contained in it and submitted
by me or •• agent to compi '.aia--plication is true and correct.
Signatur C -
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Show on Site Plan: Additional Information: ; a I
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Lot Dimensions Landscaping j , I
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Existing Structures Drainage Plan � j�-� t �--� - —
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Proposed Improvements Hydrants
Structure Setbacks Topography ' ' I
Easements Lighting ; 1 ' , f �_ _ .
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Septic
System(s) Signage ._ _ 4— --- �_ __ _. _ ' __ �_ t
Water Lines Shorelines . 1 . i I 1
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Sewer Lines Highwater Mark _ I.
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Fences,Wells
Driveway(s) — _ �—
Right of Way Width(s) ; _ ` f , �'
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Names of � }
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Flanking Street _. _ _ _-�_ �. -- a
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