1985, 12-30 Permit App 00009256 Double Wide(THIS IS NOTA PERMIT) 71
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
P0 I COMPLETE IN INK
(Please return this original and your building plans to the Department of Building and Safety)
SHADED AREAS ARE FOR DEPARTMENTAL USEI Project Number
Owner's Name LAST
FIRST
MI
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ki
Project Address (Street ame 6 Numbell) -
457 i C CUCLi D
PC
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Applicant
^ �
Address
_ 1
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1�
City
tate
zipr
Phone
C�Ja99aaj
509 (
a - a5
Business Phone
1
)
CDntractor/Agent
Address
City
State
Zip
Phone
l
)
Contact
License Number (Required)
Business Phone
1
)
Archited/Engineer
Address
City
State
Zip
Phone
)
Contact
Business Phone
Lender
Address
City
State
Zip
Phone
(
1
Describe WorkResp
CnoeL-E _ coy nE � t�)�
i
1/
Comm.
Subdivision l Plat Name/ Short Plat Number
USC -S7 FAriuS
PLAT 12 -
Assessor
Assessor Parcel Number Lot
Block
Plat Number
X552- O /--) --
Pertinent File Numbers Zen
Com Plan
Census Tract
4
Number of Dwelling/nits
Number of Buildings
Sae(Sq. Ft. l Acre)
Depth
Frontage
Front Setback
Left Setback
Right Setback
Rear Setback
RI W Width
Additional Information
Z
O
Square Footage
F
cc
ccQ
O
z
2
C7
2
J_
7
M
Number of Bnedrooms
L
Building Technician
Date
Group
i
3
Type
1 v
12-i3
rz,-
Tr' 20
Scale:
Date:
Revisions:— Attachments:
Show on Site Plan:
Additional Information:
Lot Dimensions
Existing Structures
Proposed Improvements
Structure Setbacks
Easements
septic System (s)
---
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Water Lines
Shorelines
Sewer Lines
Highwater Mark
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Tr' 20
Scale:
Date:
Revisions:— Attachments:
if
Ft
M
r■n
0
A
DEPARTMENTAL REVIEW
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 ,1ClRs'
proved Cond.
Approval
Hold
Environmental Health Application #
W. 1101 College
Room 200
Planning/Zoning
N. 721 Jefferson
/y O
Engineers
N. 811 Jef r 0
D
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 ,1ClRs'