1985, 10-17 Permit App: 00008201 Duplex0
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DEPARTMENTAL REVIEW
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.
De�ts£r. S�
Signatur Date
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(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)
Jr'IHUCU mrimma Hr m rum UCr h%m i IVICIV I HL UAC
Approved Cond.
pproval
Hold
Environmental Health Application 'cation #
W. 1101 College X4,
Room 200
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Planning/Zoning
N. 721 Jefferson
Zip
Engineers v
N. 811 Jefferson
Applicant
Address
Utilities
N. 811 Jefferson
Z 45
City
Plan Review/ Fire Prevention
N. 811 Jefferson
Zip
Phone
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.
De�ts£r. S�
Signatur Date
kP
J
(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)
Jr'IHUCU mrimma Hr m rum UCr h%m i IVICIV I HL UAC
Protect Number
Owner's Name LAST
FIRST
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Project Address (Street Name & Number)
Zip
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Applicant
Address
Z 45
City
State
Zip
Phone
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Business Phone
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Contractor/Agent
C'IZ�ATIU� }{t-te.t->r�ti �Es�Gry
Address
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City
State
Zip
Phone
Contact
License Number (Required)
Business Phone
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Architect/ Engineer
Z'Z3.62 3 / 14�$�
Address
City
State
Zip
Phone
Contact
Business Phone
Lender
Address
City
S.IV a.+:
State
Zip
Phone
Descrlbd Work
Res.
Comm.
Subdivision/ Plat Name/Short Plat Number
CLAt21cs 41LLC(2. T 4c)WOE5
Assessor Parcel Number
Lot
Block
Plat Number
-21S'4A' -1 0 3
3
1
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
_TFIZ
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
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Front Setback
Left Setback
Right Setback
Rear Setback
R/W Width
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Additional Information
Square Footage
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Number of Bedrooms
Build' Technician
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Date
IC-41-7/85-�3
Group
Ty e
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Show on Site Plan:
Additional Information:
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Lot Dimensions
Existing Structures
Landscaping
I
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TF,
411
Proposed Improvements
Drainage Plan
Hydrants
l
Structure Setbacks
Easements
Topography
Lighting
-
Septic System (s)
Signage
Water Lines
Sewer Lines
Shorelines
Highwater Mark
L
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Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
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Legal Description
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Date: Lo I I 1 �7
Revisions: Attachments:
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