1985, 10-29 Permit App 00008663 MH(THIS IS NOT A 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)
SHADED AREAS ARE FOR DEPARTMENTAL USt I
Project Number
Owner's Name LAST FIRST 1, MI
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l Zip
Project Address (Stree Name & Number)
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State
Zip
99-206
Phone
( ) 9.)?-o Z
Business Phone) S 35- , 29 21
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
Phone
1
Describe Work
Jou OLE (eh 06 C2.6 )( )
Res�..........-
Carom.
Subdivision/Plat Name/Short Plat Number
`PLtA'C A 6) 2-1•.)►4 GYLC-S 112 2 \ G 14"-c c [,j'' rL> t SToz_...
Assessor Parcel Number
C7554 — 6571 Prnl
Lot
Block
Plat Number
Pertinent File Numbers
Zone
Comp. Plan
Census Tract
Number of Dwelling Units
i
Numberot Buildings
/
Lot Size (Sq. Ft./Acre)
Depth
36C-j
Frontage
l46 t
Front Setback
S
Left Setback
Right Setback
(, 1
Rear Setback
R/W Width
Additional Information
Square Footage
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4
2
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0
1L
z
0
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a
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ca
Number of Bedrooms
Building Technician
a Ate
Date
/e-29-9
Group
1^- --
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
Additional Information:
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
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Scale.
Date: Lv (24x1455
Revisions*
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DEPARTMENTAL REVIEW
Approved Approval Hold
EnvIronmental Health Application # ..—/_q
W. 1101 College ��„ �
Room 200 "`)`1 C2/31-i.a./9-esre.4 —
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Planning/Zoning
N. 721 Jefferson
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N. 811 Jefferson /!! �j J
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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
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.
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