1986, 08-27 Permit App: 00012851 Carport (THIS IS NOT A PEF"MIT)
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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
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Owner's Name LAST FIRST MI
Project Address(Street Name&Number) Zip
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Applicant i Address
City State Zip Phone
( )
Business Phone
( )
Contractor/Agent Address
677
City State Zip Phone
( )
Contact License Number(Required) Business Phone
( )
Architect/Engineer Address
S 1m
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
L
Describe/Work (• /`ff���' e Res, Comm
Subdivision/Plat Name/Short Plat Number,
1/2/eL.l eA$/
Assessor Parcel Number / Lot Plat Number
Pertinent File Numbers Zone 'Comp Plan Census Tract"'
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth - Frontage
Front Setback Left Setback Right Setback --Rear SBtb R/W Width
Additional Information r uareFoot e
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0
CO Number of.Bedrooms
uilding Technician Date / Group
Type„
int 'a�h7'
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application#
❑ W.1101 College
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention I I
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
❑ 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
Scale:
Date:
Revisions: Attachments:
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Show on Site Plan:
Additional Information:
Lot Dimensions
Existing Structures
Landscaping
Drainage Plan
Proposed Improvements
Structure Setbacks
Hydrants
Topography
Easements
Lighting
Septic System (s)
Signage
Water Lines
Shorelines
Sewer Lines
Highwater Mark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Scale:
Date:
Revisions: Attachments:
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