1986, 05-14 Permit App 00011040 Hayshed(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)
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Project Number y le ,
Owner's Name LAST FIRST MI
t'El-IN r- k_Z L- n e c.A � l ..)_O C
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Project Address (Street Name & Number) Zip
\\\:r Ems-
Applicant
CC
Address
City
,c VVS--IL rf.__
State
Zip
9 e
Phone
( ) 9):a.-3 3a7
Business Phone
( ) gal''7 y
Contractor/Agent
r1 "v -
Address
City
State
Zip
Phone
(
Contact
License Number (Required)
Business Phone
( )
Architect/Engineer
Address
City
State
Zip
Phone
( 1
Contact
Business Phone
( 1
Lender
Address
City
State
Zip
Phone
(
Describe Work
HAV s f4E o 4 Y4)
Res.
I/
Comm.
Subdivision/ Plat Name/Short t Number
14A,vD V i Et.r& /`FC26-S
Assessor Parcel Number
• 4$5lk3--6709
Lot
Li--
Block
t
Plat Number
Pertinent File Numbers .
Zone
Aar 1
Comp. Plan
Census Tract
Number of Dwelling Units
t
Number of Buildings
2--
Lot Size (Sq. Ft./Acre)
Depth
1.01k•
Frontage
321)
.front Setback -'.
Left Setback
Right Setback
Rear Setback
R/ W Width
Additional Information
1 BUILDING INFORMATION
Square Footage
Number of Bedrooms
Building T Ician
Date
Group
Type
DEPARTMENTAL REVIEW
Approved
Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
I
Utilities
N. 811 Jefferson
I
•
flan Review/Fire Preventlo
--N. 811 Jefferson (' ryyl 1 �Mi i c-,
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l//
,e).".ai
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 i1C1 ��'�t - Date
Show nnSite Plan:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Enonmoms
Septic System (s)
Water Lines
Sewer Lines
Fenms'VVeUt
Driveway(s)
Right nfWay VKidth(w)
Names of
Fronting Street
Flanking Street
Additional Inf rmmdon:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signugu
3hnnA|nun
HighwatoryNark
/
Legal Description
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