1986, 06-03 Permit App 00011372 MHDEPARTMENTAL REVIEW
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Approval
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/ Environmental Health Application #
W. 1101 College ,
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Planning/Zoning / '"t-ie%YA
N. 721 Jefferson C d "' 6' — SG,
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Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
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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-f 3ct,
(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)
Owner's Na e
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LAST `Ir;ST
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Project Address (Street Name & Number) Zip
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Applicant
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Address _
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City
State +
' Zip
Phone �/40
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Business Phone
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Contractor/Agent
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
Phone
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Subdivision/Plat Name/Short Plat Number -
Assessor Parcel Number
15553 `o %
Lot -
Block
Plat Number
Pertinent File Numbers
Zone a
Comp. Plan
Census Tract
Number of Dwelling Units
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Number of Buildings
4
Lot Size (Sq. Ft./Acre)
Depth +
4S�
Frontage
Ico,—
front Setback
Left Setback
Right Setback
Rear Setback
R/W Width
Additional Information
I :BUILDING INFORMATION I
Square Footage
�aF�«y;
Number of Bedrooms
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.
Date
Group
Type
Show an 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)
(James of
Fronting Street
Flanking Street
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
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