1986, 04-25 Permit App 00010720 Fire Damage(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 DEP
_ V
I Project Number /el�[� �}t
Owner's Name LAST FIRST
'"'__ ' [Imo[! I� ,
Project Address (Street Name & Number) Zip
t: 17717 5;610 — 9740 16
Applicant
All.
Address /
At R-.9-- LiAs.s
City
State
Zip
ell a/4,
Phone V
(507) 9a-Y-s5a
Business Phone
Contractor/Agent
ib'Yl
Address
City
State
Zip
Phone
( )
Contact
License Number (Required)
r Cy
iq0 <0
Business Phone
( )
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
Zip
Phone
( )
Describe Work
, , 2E rJ,41-/d&c &- 1S r or.o.rC C—
Res.
Comm.
Subdivision/Plat Name/Short Plat Number
CoQa it kJ A-ao
7rO PEE i+v/EC
Assessor Parcel Number
655 i/ -- 1,25
Lot
Block
Plat Number
Pertinent File Numbers
Zone
m_R1
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
Addition I Information
2Q,000 V#tLti4-TioN
f BUILDING INFORMATION
Square Footage
,
%
.� lb i 4
Number of Bedrooms
i)nQTechniclan
Date
Group
Type
Show on Site Plan:
Add al Information:
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
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Leal Description
1
t T-
1
7
1_.
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health
❑ W. 1101 College
Room 200
Application #
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/Speclal Inspection Information
Project Representative
Phone
Address
I certify that I have examined this appl' ation and state that the information contained in it and submitted
by me or my agent to compile said appji6aa ion is true and correct.
Signature
Date