1986, 07-08 Permit App: 00011998 Pool a (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
IProject Number
Owner's Name LAST FIRST MI poti%1t .
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Project Address(Street Name 8..,N umber) , /'/ ,�/ Zip
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Applicant Address
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Business Phone
Contractor! gent Address
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City s ^ State Zip �� Phone
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Contact License Number(Re wired) Business Phone
Architect/Engineer Address
City State Zip Phone
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Contact Business Phone
Lender
Address
City State Zip Phone
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ribs Work 3'
Res. • Comm.
')..ivision/Plat Name/Short Plat Number
Assessor Parcel Number Lot Block Plat Number
Pertinent File Numbers Zone Comp.Plan Census Tract
ber of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
t Setback Left Setback Right Setback Rear Setback R/W Width
E Additional Information
Square Footage
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m Number of Bedrooms
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Show on Site Plan: Additional Information: __ _ - -- ,
Lot Dimensions Landscaping + 1 i
Existing Structures Drainage Plan
Proposed Improvements Hydrants i j
Structure Setbacks Topography I I, I
Easements Lighting — — 1 . —
Septic System(s) Signage -- _ _ ,
Water Lines Shorelines j
Sewer Lines Highwater Mark t __ _
Fences,Wells
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Driveway(s) ---- 1-- -- - -- �--�- , --
Right of Way Width(s) E ,_ �_ , x- i
Names of
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Fronting Street
Flanking Street
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Legal Description — . ,
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Revisions: Attachments:
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DEPARTMENTAL REVIEW ,.
Appro ApprovalCt.
Hold
Environmental Health Application# S7 V/� „, � 1'/�1
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❑ W.1101 College ' 'f
Room 200 141
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 examined this app ation and state that the information contained in it and submitted
by me or my ag: to compile said appl ion is true and correct. Z
i n r Date �
S g atu e
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