1986, 04-14 Permit App: 00010454 Addition 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 I Project Number �a
Owner's Name LAST FIRST MI
1(109/41
Project Address(Street Name&Number) Zip
S-0) G a E l(0 5j (dr C H.
Applicant / Address
City State Zip Phone
641 74.r rt 9 Z..b (s'f) -.5-3 y q,/3o / -
/ Business Phone
( )
Contractor/Agent Address
City State Zip Phone
( )
Contact License Number(Required) Business Phone
--f
( )
Architect/Engineer ✓� Address
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address I
City State Zip Phone
Describe Work Comm.
rtS & 4_00r DE kiCAl (/0 Y22 )4.
-=�' ✓
Subdivision/Plat Name/Short Plat Number
Assessor Parcel Number Lot Block Plat Number
2_(.063/ - Qd(o5
Pertinent File Numbers ZoneComp.Plan Census Tract
Qasue
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
� 50
Front Setback Left Setback Right Setback Rear Setback R/W Width
E sr,AJG 50
Additional Information Square Footage
2.?0 P
c. 5e >✓KtTtGU4 KoT —c--g A2V-Pr
0
2
LL
J
5
a1 Number of Bedrooms
Building Technician Date (Group Type
/ ,f ./ ii/ QE_ I P_ \/A)
DEPARTMENTAL REVIEW
Cond.
j� Approved Hold
Environmental Health Application#
i./ a • 5 if Approval
W. 1101 College 40I14
Room 200
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
❑ N.811 Jefferson
Plan Review/Fire Prevention Q�
❑ 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
Show on Site Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Oriveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Additional Information:
Landscaping
Drainage Plan..
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Scale:
Date:
Revisions'
Attachments: