Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
1986, 10-27 Permit App: 00013922 Pool
(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 Project Number Owner's NameS+ � LAST I RST Ml Pi4E N1 t Q 1-41•-b lib? fAYIr Project Address(Street Name&Number) Zi j L Z E I 3Z- S©t•Ori c_ , t,)R- 6 ! Applicant Address biu III N UL5 i (1 t' Iva t Pr nfc5 PA , CityState Zip Phone � � Til,)4 (19 ) 1%,7,--,s----2.._7,7 Business Phone ( )) Contractor gent Address Siwc I\ it/ 5' &W /bac rte, ICity State Zip Phone 1 S PO t)-P,Q _ tj--)19, ei9 tib 62 ( ) I Contact License Number(Required) Business Phone Cs, ,..x_ CitSTP�i' Ib / D t' ( s c1)'- 9 v7'--,51--717 Archi tett!Engineer Address City State Zip Phone ( ) Contact Business Phone ( ) Lender -�- Address City State _ — Zip Phone ( 1 Describe Work11) Res. Comm. "� t ( i.. i/) 4 , L� IA/tri mA N3-6-- Yatit- /41 x 3 l'' Subdivision/Plat Name/Short Plat Number Assessor Parcel Number Lot Block Plat Number Pertinent File Numbers Zone Comp.Plan Census Tract Number of Dwelling Units Number of Buildings Lot Size(Sq.Ft./Acre) Depth Frontage Front Setback Left Setback Right Setback Rear Setback R/W Width Additional Information Square Footage Ys I \ Z .(1{ 9 k }.L-. O ('iiia v oo u. A - 0 z 0 J 5 m Number ot Bedrooms Building Technician Date Group. Type ' � DEPARTMENTAL REVIEW Approved Cond. Approval Hold Environmental Health Application# /0-41 Sit y� W.1101 College .tom Room 200 Planning/Zoning ❑ N.721 Jefferson Engineers ❑ N.811 Jefferson Utilities ❑ N.811 Jefferson Plan Review/Fire Prevention ❑ N.811 Jefferson Other(SEPA/Critical Material/etc.) 0 ❑ Fast Track/Special Inspection Information Project Representative Phone Address I certify that I hie examined this application and state that the information contained in it and submitted by me or my age to compile Id application is true and correct. /C)XSignature i Date 7 Show on site Plan: Existing Structures Proposed Improvements Structure Setbacks Easements Septic System (s) Water Lines Sewer Lines Fences, Wells Driveway(s) Right of Way Width(s) Names of Fronting Street Flanking Street D Additional Information: Landscaping Drainage Plan Hydrants Topography Lighting Signage Shorelines Highwater Mark L - Scale: Date: Revisions: Attachments: