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1985, 09-17 Permit App: MH
#.......,.. a2J2/-.,-- --vf _ 91,...._,,, -5 al-4.te„;:,42.7.,.__„(i.e.........i .A.A.,t.............. e eildere: , - . y� BUILDING PERMIT (THIS IS APPLICATIONNOTAPERMIT)WORKSHEET PLEASE PRINT AND COMPLETE ONLYCOMPLETE THOSE PARINTS OF THE FORM YOU UNDERSTAND INK (Please return this original and your building plans to the Department of Building and Safety) SHADED AREAS ARE FOR DEPARTMENTAL USE t Project Number Owner's Name ' . LAST FIRST MI J t (J e Project Address(Str me 8.40/Nurnberg"' V Zip /`/`11/f—C' ,2 v li _ r 9 � Applican r Address City State i Zp, 9.0. ,. , Phone ( �� / O !J//ja_c_it„..t‘j Business Phone vi i Contractor/Agent Address City State I Zip — Phone -- 1 l ) Contact License Number(Required) Business Phone ( f 1 Architect/Engineer I Address City State I Zip — Phone I ( ) — Contact Business Phone ( I Lender I Address City State I Zip Phone lI ( ) Describe Work A;i4Eitfc.,.. )y Res. Comm- 2. . •-• . SubdM ofl1PiatkNameI.Short Piat Number : ` ,. , ,. • ... • . .. K,� � +B. --� tn.'iii ..�5 (, .. t. - .... .. � 'ar Number III' y Block Piet Number rt ('— 2Ane i om' Plan; Census Tract . .! i�arttnent#fiJa Numbers Numberol Dwelling Unita ' Number of Buildings lot Size 4SQ Pt IAcre) a Depth Frontage-' y ig •Ptont$ r ar a y t ett sett acl v '�3 it". atr- s t / tf#ktf(nitt�OFr,a , ,_ s • t ar - .,.-, S�uerefoot ,..i.,.;,:,,,.:,,,--- ., t ..'sr e*^};,4 '' n i.sH ." a,..,+ ..tr- st.r--, 'S.- -,s's :.+,'^ � x { ^ - x ` + s �.tY_ . AC ..:.:.--.'=;,-,:-.,,,-,.4--:,=,.. .,:n'..-..,„-,,,':;.,„,.!,,... ;?:; 1. : .x�a9� ' � x. "�`Y 'r=" r..s rOTYPe - s.-.- 1' . $ " ? a w , ;Group C2 -Gate3uiiding Technician 11Z�BC tiM - Show on Site Plan: Additional Information: Lot Dimensions Landscaping Existing Structures Drainage Plan Proposed Improvements Hydrants __ . ;___ _____, Structure Setbacks Topography I I I Easements Lighting _ r 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 -a- Legal Legal Description ---� ' #4 Pl ©F I 2 z o 1= w (�/,o of `/z OF . 1/4L F 1/7- w � i�z OF 4 • • 1 -11111•1.Scale: Date: Revisions: Attachments: 1� • I I I 0 q • • • ((Q DEPARTMENTAL REVIEW Cond. Apprived Approval Hold Environmental Health Permit Number _ 0"). ri W. 1101 College Room 200 I I C1c� Planning/Zoning I „_ t,K�N"721 Jefferson IIAlj..0 uL&H IF .S -1--13P,r_A is Permit Numbe Engineers 1 N.811 Jefferson Utilities N.811 Jetferson l Plan Review/Fire Prevention 17 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 is true,correct,legal,and binding. Owner's Signature Date