1985, 03-25 Permit App: 00004651 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 Owner's Name (las (first) (m)
(.:*-1-"°•.k.::\-- \‘‘ t1. vC `W
Department Only
Res. / Comm
I
2 Project Address (not Mailing Address) or�Road Name pace Zip
j
."City /Communit
i� �. v` V\L.�.._. -Q. S
State
Subdivisio Plat Name
tic p r �.. `'l �� ��� U\•
4 Assessor Parcel No.
\ S 71_ — 0 -1
Lot
Block
.. * * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone S_T Project No. i
�TJ
1
5 1
6 Dwell # I
I No. of Buildings
Sq. Ft. /Acre
Depth
Frontage
7 Set B
eb Frrroont
I (L)S-1
`
�(R)S- J
i I{
`Read
Census Tract
I Module No.
Initials
16 Architect Firm Name
Street Address
Zip
I City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
License No.
Phone if different than above
( )
8 Owner /Agent (if different than #1 above)
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Business Address
\-. ...r� \.\. -\,:t' C v
9 Zip ^^
City
State
"
Phone
12 Review Required
Plan Check /N)
Other (Y /N)
SEPA Exempt (Y /N)
Date
15 Type Work 'Bldg
❑ Fire
❑ MH
❑ Demo
e-New
C Add /Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
re %deN( e)
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
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MF _ e&c, t
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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;
7 -/77
APPLICATION #
❑ Residential
❑ Bldg alteration /addition
Planning /Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w /d; ❑ lot size; ❑ use /zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions /Comments•
Engineers: ❑ Commercial;
N.811 Jefferson ❑ drainage
❑ road improvements
Conditions /Comments•
❑ Residential;
❑ new access /approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions /Comments•
Other:
Plan Exam
Fire Prev.
rocs ?�I
� -a
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
Release
Release
w /cond 1
Hold 2
/G s
Planning /Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w /d; ❑ lot size; ❑ use /zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions /Comments•
Engineers: ❑ Commercial;
N.811 Jefferson ❑ drainage
❑ road improvements
Conditions /Comments•
❑ Residential;
❑ new access /approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions /Comments•
Other:
Plan Exam
Fire Prev.
rocs ?�I
� -a
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
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