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1986, 09-02 Permit App: 00012914 Deck 7 (THIS IS NOTA PERMIT) BUILDING PERMIT APPLICATION WORKSHEET LEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND 3 it. r"' ? a `""4" 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 / Owner's Name LAST FIRST MI Project Address(Street Name&Number) Zip E. ,' J 5tl ii-rAve 1?e,,V 14,41 A- qe12 14. Applicant Address tio'144144-f' 4,A. 45-Gag 1)Ili AXE _ City State Zip Phone o WA let iC ( ) qzfil.*-478/ Business Phone V4SNE: Contractor/Agent Address ( ) City State Zip Phone ( ) Contact License Number(Required) Business Phone ( ) Architect/Engineer Address City State Zip Phone 1 ( ) Contact Business Phone ( ) Lender Address City State Zip Phone ( ) Describe Work �� Res. Comm. pf c I-=- A(�v in o 1.---- Subdivision/Plat `Subdivision/Plat Name/Short Plat Num WC'LFP.k.E57 4).2Ci- iv 0 Assessor Parcel Number Lot Block Plat Number 'f ..M 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 Setback G Rt W Width Additional Information Square Footage - z 0 I- 2 cc 0 L z 0 z o — J_ 5 m Number of Bedrooms Building Technician Date Group Type 1-3a1o1 . 12 -g4c- r 3 . DEPARTMENTAL REVIEW Q(1 Approved Cond. Hold Approval Environmental Health Application I © , d . W.1101 College Room 200imalarb 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 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 1, us I r , 1 ' i ' II • I ' 1 1 1 i . • ,. , , , 1 ! us, , . I , 1 1 t it '4 -1 1 1 1, 1 -1 i 1 1 , '1 II 1 ! , , Show on Site Plan: Additional Information: ' A t i'' -g--- . MEI ' I I 1 I 1 __.. __. . —-I--i Lot Dimensions 4 Landscaping ----- -4.---1-- 1 4- I . 1----) Existing Structures') Drainage Plan i ; al ,z . 1 i ! ! I i I I ' i I- vil ' i , i Proposed Improvements Hydrants ---4-- 1 ft! 4: : -• __i • ' ' • .. . z 7 r ' 1 • I I 1 Structure Setbacks i Topography ! 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