1985, 06-03 Permit App: 00005811 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 Owne
's Name a (last) (first) (m)
i l CCS 1 � �,.1,�. -C ,
D
Me. !Comm
2 Project Address (not Mailing Address) cr Road Name Space Zip
v\i.. iz.c, 140 2)
3 Ity /Community
L._.) f7.....Q. Q. -n_ CA-C- k...2.---•-
State
ba).--'
Subdivision/Plat Name
K r-L ks__44 6 c_k_`_7(1,\,(..__-Lk_ -Mj ,
4 Assessor Parcel No.
'r-: t i C-7- '" oe:›/ !',
Lot 1
( Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone Project No. 1
r (2- J
-Sq.
6 Dwell #
l
No. of Buildings
1
Ft. /Acre
Depth `
(3—)
Frontage ,
8t
7 Set Back -Front --
(L)S-1
c.
(R)S -2
Rear
Census Tract
Module No.
rn ' Is „�
16 Architect Firm Name
t o r
Street dd ess
^-0
Zip
7
State ,
\k irk- `
( ,
Contact Person
Phone if different than above
Contractor Firm Name „.,‘.
Address
Leis -3a
f\) c`I,t 1(l t � .C_.
Zip
-1c�
City
C`
State
14..A.--”
Phone i
(� (,) ?--Z --"2— 3
_5
Cont n
"CV- - _tf-- -C7,,- -)Ann
se No
tiCT - 2_ISL -_a
Phone If different than above
( )
8 Owner /Agent (if different than #1 above)
c
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
X New
❑ Add /Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
R E- s
10 Applicant Name
CT ^
�� n
Strgaf cw-1s tsy.__
11 Zip
City
State
Phone
( )
Lender
11.a., (5L-nt, t D\R---r)
Street Addre s +
Zip
`tea C(
City
State (
` ' -(.3
Contact Person � '
Phone if different than above
Additional Information
HF — C1itd 84/5 P/4,j
u13 = N 'sae ,4 er or
DPe4- =g6
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 ❑ Commercial;
W. 1101 College ❑ New Construction;
Room 200 ❑ Additional structure; _
APPLICATION # U
Conditions /Comments e,�� ✓�(4 v 1t�
p�/
❑ Residential
❑ Bldg alteration /addition
Release
Release
w /cond 1
Hold 2
Or
Planning /Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w /d; ❑ lot size; ❑ use /zone; i- • --- . A
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions /Comments:
Engineers: ❑ Commercial;
N. 811 Jefferson ❑ drainage
❑ road improvements
Conditions /Comments• Fi\ T319
❑ Residential;
❑ new access /approach;
❑ Flood Plaiai`j
❑ fence; Hog t.
Utilities:
N. 811 Jefferson
Conditions /Comments•
a
N
C
Other:
Plan Exam
Fire Prev.
Conditions /Comments•
Information
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
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