1986, 12-10 Permit App: 00014488 Hayshed(TM -5'1S srOi A<PERM IT) Set
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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owners Name LAST FIRST Mt
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Project Address (Street Name & Number) 331�p''
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Address
City
State
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Phone
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Zip
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Phone
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Show on. Site Plan:
Additional Information:
Lot Dimensions
Existing {tructures
Proposed Improvements
StructureWhacks
Easements '°
Septic System(s)
Water ❑nds -
Sewer Lines
Fences, Wells
Drlveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Landscaping ,\
Drainage Plan
Hydrants
. Topography ,
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
•
Scale:
Date:
Revisions: Attachments:
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DEPARTMENTAL REVIEW
Environmental Health
L 1 W. 1101 College
Room 200
Permit Number
Approved
Cond.
Approval
Hold
Planning/Zoning
O N. 721 Jefferson
Engineers
O N. 811 Jefferson
Permit Number
Utilities
O N. 811 Jefferson
Plan Review/Fire Prevention
❑ N. 811 Jefferson
0
0
Other(SEPA/Crltieal Material/ate.)
Fast Track/Special Inspection Information
Project Representative
Phone
Address
1 certify that I have examined this application and state that the inform Ion contained in It and submitted
by me or my agent is true, correct, legal, and binding.
Owner's Signature Date