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1986, 07-23 Permit App: 00012276 Residence (THIS IS NOT A PERiviIT) 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 I Owner's Name LAST Ci EST Ml Project Address(Street Name&Number) ..►IA Zip C,12-1,2k 3Zar.F r = Applicant Address S7E a/. - C d _ate?R_1.t t.-T tv_' L -- o. 30 , iso3 OG CityTState i Zi Phone 5p a K w 1_`iz.._i Li: ( '1y) S`2- f3 - -- Business Phone Ski Contractor/Agent Address ,‘__/'-' Sk 4 ...4-- c_a_e..)_s_raiLt..Lc City tate Zip Phone Contact License Number(RRequired) + Business Phone 5 j fLIi(e V ( ) Architect/Engineer O Address ��.�. TV/ City State I Zip Phone ( ) Contact Business Phone I ) Lender Address City State ! Zip Phone I ( Describe Work Res. Comm, I_ f CSCE t OP,4pAGE Subdivision/Plat Name/Short Plat Number 1-_/ir / tee '/-7-4 ;Wester Parte!Number LotBlock Plat Number - 4/ - ( /4- Pertinent File Numbers Zone Comp.Plan Census Tract Numberof Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage /l.t <71 Front Setback Left Setback Right Setback Rear Setback R/W Width 125 ' /``, r, ; Additional information Square Footage (qr/' I fir— Z o Pa r--)51, --r- PA . 2 r 0 U- z o Z 5 m Number of Bedrooms Building Technician Date Group Type r �, 9I� s T DEPARTMENTAL REVIEW Cond. ApprovedApproval Hold 12/ Environmental Health Application# IVA W. 1101 College Room 200 CJ/D c' L'tf. Planning/Zoning ❑ N.721 Jefferson _ 9„....... % /4/ �..,�ngineers c1 tLd' N.811 Jefferson 4� `&O Utilities 1 ❑ N.811 Jefferson LLL... Plan Review/Fire Prevention 0 N.811 Jefferson Other(SEPA/CrItIcai Material/etc.) 0 El 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. f i Signature 71 'L - Date E Show on Site Flan: Lot Dimensions Existing Structures Proposed improvements Strt-cture Setbacks Easements Septic System (s) Water Lines Sewer Lines Fences, Wells Oriveway(s) Right of Way Width(s) Names of Fronting Street Flanking Street Legal Descri Additional information: , Landscaping Drainage Plan Hydrants Topography Lighting Signage Shorelines Highwater Mark Scale: Date: Revisions: Attachments: 5