1986, 03-24 Permit App 00010152 MHDEPARTMENTAL REVIEW
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Approved
Cond.Hold
Approval
Environmental Health Application #
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W. 1101 College
Room 200
Planning/Zoning
721 Jefferson
N.
Engineers
N. 811 Jefferson
Utilities
N. 811 Jefferson
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Plan Review/Fire Prevention
N. 811 Jefferson
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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
/6'Date0
(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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Owner's Name LAST FIRST MI
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Project Address (StreetSName & Number) _ / ) /
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City/2 (
State ,) j
Zip t
Phone `I
Business Phone
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Contractor/Agent
Address
City
State
Zip
Phone
( )
Contact
License Number (Required) "
Business Phone
( )
Architect/Engineer
Address
City
State
Zip
Phone
( )
Contact
Business Phone
( )
Lender
Address
City
State
I Zip
JI
Phone
Describe Work
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Comm.
Subdivision/Plat Naine/Short Plat Number
Assessor Parcel Num r
Lot
Block
Plat Number
Pertinent File Numbers
ZoA IL'
Comp. Plan
Census Tract
Number of Dwelling Units
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Front Setback : 2:
Left Setback
Right Setback
RearSetback..
R/W Width
Additional Information
BUILDING INFORMATION
Square Footage
Number of Bedrooms
Group
A-(— l
Type
Building Technician _/
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Date
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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
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
111
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Scale:
Date:
Revisions:
Attachments:
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