1986, 06-05 Permit App: 00011412 Addition I
(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
Project Number
Owner's Name LAST FIRST MI
Project Address(Street Name&Number) Zip
/ TO
Applicant Address
City State Zip Phone
( Sa/l ) S3 r-c(07 )-
Business
-Business Phone
( Via) ) 1 �-6(x,r--
Contractor/Agent Address
City State Zip Phone
( )
Contact ^ License Number(Required) Business Phone
Architect/Engineer Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender
Address
L
d �' tc�t at.�15 Y.„ ct.2 r ,,�
City State Zip `+1P'hone �j 6�Zn1 � 'V `C�
�J/1o/ti1.4-4 (LJ/4— I l j��d( �_ ( ) ', .,1t90�
�DescribeWork ` I Res. yComm.
Subdivision/Plat Name/Short Plat Number
L L U=Li r ,/ , ft'kG "-Z-NP
Assessor Parcel Number Lot Block A Plat Number
Pertinent File Numbers Zone V
Comp.Plan Census Tract
Number of Dwelling Units Number of Bjiildings Lot Size(Sq.Ft./Acre) Depth 1 Frontage
1 I 15-1 TiO
Front Setbacks - ,* I Left Setback 1 i t Right Setback �,J Rear Setback R/W Width
Z.
Additional information
Square Footage
nil .r: rtvrer
z Fe> •7 r2-79 Pi
, • o
a
cc
0
LL
z
z
6
J_
5
m Number of Bedrooms
Building Technician Date Group Type_
DEPARTMENTAL REVIEW
Approved CHold
Approval
gi Environmental Health Application M 630/-7_
4s`1 I •
w.1101 College
Room 200 IA.•� /t
Planning/Zoning 4.e. u
M N.721 Jefferson
•
Engineers
❑ N.811 Jefferson
sK- Utilities / Of
N.811 Jefferson / C ./ 14 A /
-2/f1 r ' or V — ��—X�•
Plan Review/Fire Prevention
❑ N.811 Jefferson
Other(SEPA/Critical Material/etc.)
o 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
- I I I I I Iii,. ' 1 , ! I 11 I 1 ,, , I
���, .,c_____,....;
�, 1,,,,:t:
A , ,
Show on Site Plan: Additional Information: - -_ _ I - `
Lot Dimensions ._ _
Landscaping I I 1- i I �. } - • I 11 , —
:
Existing Structures Drainage Plan --- -- i; - -- ,-1-- -- - - } I - - € ):° '
g . t. t { )----1---!-----4-•---7(=--- -Tf --t - --1-- S . -_t` I_l _ t Vit.
:
:
Proposed Improvements Hydrants
i
Structure Setbacks Topography 1 1.. L w ' t
t j
Easements Lighting �_. ! j __- _. __-,-- :_-- i_r-. _ { ,
•
I -_: k _ , I ,
1 + .
Septic System(s) Signage �_-._- ,:; , - I- -F ; 1 j ! � ( ,� a�w i
Water Lines Shorelines 1 I i I I _— r f 1 1: t _ --- I j .I - - .- --t- -1.--. _.__ -. '
Sewer Lines Highwater Mark __,_______I____±—__4-------1----.1 ___ E
ytv e:. — j _ j
—s A
Fences,Wells I - - - -I I
1
Driveway(s) I I t +
I
Right of Way Widths ( I _... — _I' I I ' �.`'i --- I ' .1„!
J L II-
_... — -� �-.... Yon
Names of I 1 I + I „a•" --L--r � - -} , •
� �
Fronting Street t I _ _ -_, � y �` x, { ,e6
g ' ; 1 Rsto v C I t -t t -T ti - i
Flanking Street _ r- I , — , I .. -I_ �-- ' t - —'-�— -.4__.4 _...1-__ ...,..4„.___;--1 , .._ 1,, .- rye, , j I
i I III . ( 1
I j
I
I
•
.
- .
r Legal Description - ---r---- _ _ - ! { L-! -? 1. -_ ; r - + - _ -
t
I
I � ,
—_ _—-_-.--....__r-_.— - €. - 1 • -
I
I
r�
7 , III
1 : # t1 1 i _ _ _ __ -
•
• ,
i +
I_ '
:
:
f
_
J. __ _ 2.; - k r
[ t_.
{
1 1 I I , I '�N
1 I 1 1 , •
v I
: {
:
! nfWA I ! i !
I _
4
•
, f ,
Y _
� f
—
�� J
I j I !
I : I
.
_______,____,___,___.____.,.__4_- -
I
,
:
I _- _ , `,.
I
, ttoa
3
t {
1 � .! — s'_
:
4 ,r ' .`cam d
1
7
s
. r
! 1
i I I
I I
-t i
T I t t. j .
i E 1 1
1
I
I
- T
ii ;
— . I •
I ,
j I
_:
1
1 1,
I i I I i - __ I i }
}
1
I
f 1
T 1.
_E_',—__)__ _...— , , , t_ _ }_. !_ _ —__1 I f -- } 1__} __ _ __ } ____ . }_ I I Z.. H - ' --
_j — I _ - - I — — — — — — — —i 1 —
T �! a _ I It
Scale. i I , - -
:
I ; , I I , , 14 I I L I
I 1 i 1
Date: 1 1 j
I !
€ I
Revisions: Attachments: i • — --
1I I j — i —i I I -f-- I I
,