1986, 07-11 Permit App 00012062 GarageDEPARTMENTAL REVIEW
Approved
Environmental Health
W. 1101 College
Room 200
Application #
Cond.
Approval
Hold
Planning/Zoning
El N. 721 Jefferson
Engineers
❑ N. 811 Jefferson
Utilities
❑ N. 811 Jefferson
Plan Review/Fire Prevention
❑ N. 811 Jefferson
111
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
(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)
Project Number
Owner's Name LAST FIRST MI
1vA 6 f/1IEZ 5.
ProjectAddress if -0eet Name Number �L /' ( p 4 ��2/� a {rL��
Z ft".`�.2_ lJf (fZip
Applicant
Address
City
State
Zip
Phone
Business Phone
( )
Contractor/Agent
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
Business Phone
( )
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Add ess
City
State
I Zip
Il
Phone
(
Describe Work
� 1 iI
?- 1, i_ t, (- i__i l" / _ c.O . - E ` �' '�i -'_.4
y 1 \NET
Res. , /�
V
Comm.
Subdivision/Plat Name/Short Plat Number
--,OU ,4 ( Li t AP
Assessor Parcel Number
Lot
Block
Plat Number
Pertinent File Numbers
one_'_
Zone________
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
1
Front Setgack
i� , r Y,
Left Setback
Right
, 9 _ 1
Rear Setback
R/ W Width
Additional Information
IBUILDING INFORMATION I
Square Footage
Number of Bedrooms
Building Technician
Date
�j/
Group
Type i
Show on Site Plan:
Lot Dimensions
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
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark