1986, 04-09 Permit App 00010390 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)
Project Number
Owner's Name FIRST MI
q' f� LAST
Project Address (Street Name & Number)
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Applicant
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Address
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Phone
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Business Phone
Contractor/Agent
Address
City
State Zip
1
Phone
Contact
Contact
License Number ( [educed)
Phone
( )
Architect/Engineer
Atloress
City
State
Zip
Phone
Contact
Business Phone
( )
Lender
Aodress
City
State
1 Zip Phone
( )
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Describe Work -
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Res.
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Comm,
subdiytsion/Plat tJameIShort Plat Number
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Assessor Parcel Number
Lot
Block
Plat Number
Pertinent Pile Numbers
Zone
Comp.{ Comp. Plan
Census Tract
Number of DwellingUNts
Number of Buildings
Lot Size (Sq. Ft./Acre)
Depth
Frontage
Front Setback
Left Setback
Right Setback
Rear Setback
RIW Width
Additlonai Information
BUILDING INFORMATION I
Square Footage
S3 F PS 4
Number of Bedrooms
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Group
R-3
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Show on Site Plan:
Additional Info.
,lion:
Lot Dimensions
Existing Structures
Proposed Improvements
StructureSetbacks
Easements
Septic System (s)
Water Lines
Sewer Lines
Fences, Wells
Driveway(s)
Right of Way Width(s)
Names of
Fronting Street
Flanking Street
Landscaping
Drainage Plan
Hydrants
Topography
Lighting
Signage
Shorelines
Highwater Mark
Legal Description
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DEPARTMENTAL REVIEW
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Approved
Approval
Approval
Hold
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/ Environmental Health Application# J (.t ! 3,/
W. 1101 College
Room 200
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Planning/Zoning
N. 721 Jefferson
Engineers
N. 811 Jefferson
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