1985, 06-03 Permit App: 00005810 ResidenceBUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
1 Oner's Name
Ndt 1 ( Cn
(<last) (first) (m)
r%.,`p -C A,C�
Department se Only
es. Comm
2 Project Address (not MNailing Address) or Road Name Space Zip
N, ,' 2 f---c._, 4-c3 rk
3 City /Community
State
Subdivision /Plat Name / -4ciad, ,
4 Assessor Parcel No.
Lot
1
Block
. * * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone � Project No. '5510
6 Dwell #
No. of Buildings
Sq. Ft. /Acre
Depth
Frontage
7 Set Back -Front /
I (L)S -1
(R)S -2
t Rear
Census Tract
I Module No.
i is
16 Architect Firm Name
1)r" (al
z L
Street Address
t L bltil Sly
Zip
at
City
State
L,t)
Phone
( )
Contact Person
-
4
F r i in
Phone if different than above
( )
Contractor Firm Nam r
Street Address
Zip (� (0
G�. - -�-e —
[State Cam'
Phone ) (1 c,3 . -2i. Ll--
Connttact Person /'
Licenss�eNo.
Phone if different than above
8 Owner /Agent (if different t an #1 above)
C -i1"-Q
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y /N)
Other (Y /N)
SEPA Exempt (Y /N)
Date
15 Type Work Bldg
❑ Fire
❑ MH
❑ Demo
New
❑ Add/ Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work ^;
(1/ S-1-0 RSZ f)tCQ IL-tr-1 -1--(k 74 *
10 Applicant Name
r{ ``
Nr\ t-- J �� C4XlL�
Street Address
> 51 �_J /L Et�C' L
11 Zip
City
State I
Phone
( )
Lender
U3 e i�
Street Address r�
L_t_) ,1 *,--7
Zip
1F1 D1
City
State
Loa__
Phone
( ) `3D-C, -135-
Contact Person
Phone if different than above
Additional Information
ti F 1---- Ie)Ce
try = (l8 Si4Mt As /500 /i A F
Deck= Fe)
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
Conditions /Comments•
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration /addition
Release
Release
w /cond 1
Hold 2
APPLICATION # j71
-�/ /t/7tS
Planning /Zoning:
N. 721 Jefferson
Conditions /Comments:
❑ Commercial;
❑ Setbacks;
❑ CU, variance, zone change; shoreline;
❑ Cert. of Exemption;
❑ lot w /d; ❑ lot size;
❑ fence;
❑ Frontage;
❑ use /zone;
❑ Other
Engineers:
N. 811 Jefferson
Conditions /Comments•
❑ Commercial;
❑ drainage
❑ road improvements
❑ Residential;
❑ new access /approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions /Comments•
Other:
Plan Exam
Fire Prev.
Conditions /Comments•
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
7114 .40-]
P-108 -Pr
,i-ot — Blocit) I
Sri < (Lr) 6
02115 410
auto. coo
;N
c_d 6Q
-,vc
45TH l D304 ,DR-
4 e
u
eS114) .60
z!
Ivco @a.,Q,LOr'1
t()(
i\61 cos(A