1986, 10-01 Permit App: 00013386 MH 1
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
F.Project Number
Owner's Name LAST FIRST MI
i
J��n� All . , ,
Project Address(Street Name&Number) Zip
Applicant Address
/ 1'?e�i I ,.2. o� So he u e l
City State Zip Phone
!�``�V Cid l� ,,,,,,..„.4 9963 (Say' �'. �-So g 7
Business Phone
11 �"` Contractor/Agent Address
City State Zip Phone
( 3
Contact License Number(Required) Business Phone
( )
Architect/Engineer
Address
i
City State Zip Phone
( )
Contact Business Phone
( )
Lender Address
City State Zip Phone
( )
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Res, Comm.
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Subdfxig(on/plat Name/Shoo Plat Number
A $arcel Number 'y< Lot Block Plat Number
f fi° ,m Zone /� Comp.Plan Census Trad
Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage
x 1.
Left Setback Right Setback Rear Setback R/W Width
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AOdltlonal Information
� › � % Square Footage
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etO
u.
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Z
agar y ? Q
co Number of Bedrooms
ingTechmCi �e Group Type sfyit/ j5 YP
1
DEPARTMENTAL REVIEW
Cond.
Approved Approval Hold
Environmental Health Application# - ` /
W.1101 College
Room 200 _ /0 / b
wetzei,Lvf (
Planning/Zoning
❑ N.721 Jefferson
Engineers
❑ N.811 Jefferson
Utilities
O 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 ' `1 Date l !
Legal Description
Show on Site Plan:
Additional Information:
Lot Dimensions
Landscaping
Existing Structures
Drainage Pian
Hydrants
Proposed Improvements
Structure Setbacks
Topography
Easements
Lighting
Signage
Septic System (s)
Water Lines
Shorelines
Sewer Lines
Highwater Mark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Legal Description