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1986, 01-06 Permit App: 00009320 BLDG1-0 (THIS IS NOTA PERMIT) 4� 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 UEVAH I Mtry I AL U5t Project Number C ' Owner's Name —�� LAST ` FIRST MI \ Project Address ($tre9'1 Name & Numb Zip L4 95��� Applicant S-�-.e �-e I Address -1-% Y\V " " y State � Zip Phone ( ) Business Phone Contractor I Agent Address City State Zip Phone Contact License Number (Required) Business Phone Architect/ Engineer Address City State Zip Phone Contact Business Phone Lender Address City f State Zip JPhone 7 Describe Work Res. Comm. V Subdivision/ Plat Name/Short Plat Number{ J a � � �}- �7 1 1` -t t Assessor Parcel Number Lot 6 Block Plat Number -4.4 zq 1 ----�' 0% OE3 / D 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 Z O Y`"o � WV _ — — Q � J _ O LL _Z 0 Z � -- t J_ N Co Number of Bedrooms j 1 — i Building Technician Date Group Type 01 u 0 u DEPARTMENTAL REVIEW 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. Signature Date Approved Cond. Approval Hold Environmental Health Application # W. 1101 College 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.) 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. Signature Date Show on Site Plan: Lot Dimensions Additional Information: Landscaping Existing Structures Drainage Plan Proposed Improvements Hydrants Structure Setbacks Topography Easements Lighting Septic System (s) Signage Water Lines Shorelines Sewer Lines Highwater Mark Fences, Wells Driveway(s) Right of Way Width(s) Names of Fronting Street Flanking Street