1986, 03-20 Permit App 00010132 Fire Damage(THIS IS NOT 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)
VIir.L,�IJ,-...1-r,I,r-sIII_I VIIi_l 1_,r,II1WU-1,1I,,,10,
Project Number
I tJ�.7!i
Owner's Name LAST FIRST MI
Project Address (Street Nafne & Number) Zip
(F___<-3_,,4
Applicant
Address
City
State
Zip
Phone
( )
Business Phone
( )
Contractor/Agent
Address
City
--S 0401—.0-z_e
State
C---e..1
ip
? 1-07
Phone
( ) > / ' 82--- 6 C/.5e'
Contac
License Number (Required)
Business Phone
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Add ess
City
State
I Zip
Phone
Describe Work 3 \
, ,q
Res.
Comm.
L.��
Subdivision/Plat Name/ ort t Numbei
•
..15Pi&I Oro To C, 'C NAerkE�
Assessor Parcel Number � /
I. j
Lot
Block
Plat Number
Pertinent File Numbers
Zone i�[
Aar,
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
•FrontSetback •
Left Setback
Right Setback
Rear Setback.
R/W Width
Additional Information
n . VAL.,c.r 4 Tr n A.)
I BUILDING INFORMATION
Square Footage
. t,
Number of Bedrooms
Building Techniclan
Date
Group
Type
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
Additi- -I Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
DEPARTMENTAL REVIEW
Environmental Health
❑ W. 1101 College
Room 200
Application #
Approved
Cond.
Approval
Hold
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