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
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CityTState i Zi Phone
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Business Phone Ski
Contractor/Agent Address
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City tate Zip Phone
Contact License Number(RRequired) + Business Phone
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Architect/Engineer O Address ��.�.
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City State I Zip Phone
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Contact Business Phone
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Lender Address
City State ! Zip Phone
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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
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Additional information Square Footage
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m Number of Bedrooms
Building Technician Date Group Type
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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„.......
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�..,�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
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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