1985, 11-04 Permit App: 00008592 Residence (THIS IS NOTA PERMIT)
BUILDING PERMIT APPLICATION WORKSHEET 362
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 NIIi7MZ
LAST FIRST MI
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Project Address(Street Name&Number) Zip
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Applicant , / Address
izi
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City Stat Zip Phone
4 Business Phone
( )
Contractor/Agent Address C-\
c;Z/q l' / At P9te/71 a-
City State Zip Phone
Contact - License Number(Required) Business Phone
24 Pi /4/A1/92,4,/ /I,/ D c 3 0 / ( LS9/776--
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State I Zip Phone
( )
Describe Work „` Comm.
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Subdivision/Piat Name/Short Plat Number ,.I
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Assessor.Parcel Number Lot Block Plat Number
236Z/171 -* 51
pertinent File Numbers zone comp Plan Census Tract
Number of Dwelling units Numbot,uildings Lot$€ze(Sq.ft./Acre) 7Depth., Frontage
Front Setback Left back Right t k , Rear; R/WWidth
c r a Ft� r9 .
Additionafirrforrnatiart w, F =c ucitr�►e
x 'st # 'gid '” a f t
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�.-Numberrof.Bedrooms ,
Building T olden . e Gr Type 4E
Show on Site Plan: Additional Information: o j
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
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street --
Legal Description
Scale:
Date:
Revisions: Attachments:
•
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application# SIC-0 F"
W.1101 College 715 4j
Room 200
Planning/Zoning
❑ N.721 Jefferson
>, sa /� �s/Engineers
N.811 Jefferson AlLeg- 6A?
Utilities — I
❑ 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.
Signatur / Date 1//471/13----
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