1985, 07-18 Permit App: 00006679 Residence(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)
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DEPARTMENTAL REVIEW
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
Approved
Cond.
Approval
Hold
vironmental Health Permit Number
1101 College
m 200
FW.
Planning/Zoning
N. 721 Jefferson —
Permit Number
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
Plan Review/ Fire Prevention �1
N. 811 Jefferson ,1-c; (�
Other (SEPA/ Critical Material/etc.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
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
FLAN NO. 500
ALT.- EL EVATlON
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Additional Information:
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
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Legal Description
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Scale:
Date:
Revisions: Attachments:
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