1986, 06-23 Permit App: 00011776 Garage I
(TF IS NOT A r,LRMIT)
BUILDING PERMIT APPLICATION WORKSHEET /2:1 5�)
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
Project Number //71
Owner's Name LAST FIRST `, MI / (G/
Project Address(Street Name&Number) Z'
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Applicant Address
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City State Zip Phone
Business Phone
ContractorlAgent Address
•City State Zip Phone
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Contact License Number(Required) Business Phone
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Architect/Engineer Address
City State I Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
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DEPARTMENTAL REVIEW
Approved Cond. Hold Approval
Environmental Health Permit Numbed
❑ W. 1101 College Os
Room 200
Planning/Zoning
❑ N.721 Jefferson _
Engineers Permit Number
❑ 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 examined this application and state that the information contained in it and submitted
by me or my age true,correct,legal,and binding.
/Owner's Signature -o Date � � _
Show on Site Plan: Additional Information:
Lot Dimensions Landscaping
Existing Structures Drainage Plan
Proposed Improvements Hydrants
Structure Setbacks Topography
Easements Lighting
Septic System(s) Signage
Water Lines Shorelines /
Sewer Lines Highwater Mark
Fences,Wells J 1 j 7 t•.J,i ? (,,
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street 5F1)
Flanking Street P9_a
410) Ii
Legal Description
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Scale:
Date:
Revisions: Attachments:
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