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
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LAST
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Project Address ($tre9'1 Name & Numb
Zip
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Applicant
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Address
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State �
Zip
Phone
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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{
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Assessor Parcel Number
Lot
6
Block
Plat Number
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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
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Number of Bedrooms j
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Building Technician
Date
Group
Type
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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