1985, 03-25 Permit App: 00004840 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 (last (first) (m)
\.)..._.."-- \C....._ C51—NtN
Department Use Only
Ras. ✓ Comm
I
2 Project Address (not Mailing Address) or Road Name $pace Zip La
1
.\� �[1 Z �C-. Sire e / I �� \ `V
3 City /Community
State
te
Subdivision/Plat Name
4 Assessor Parcel No.
.(io t ,,S 5 c_-,--7
Lot
S
Block
` * * . DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone Project No.
6 Dwell*
No. of Buildings
1
Sq. Ft. /Acre
Depth
/3 7
Frontage
ego
7 Set Back -Front
:---7
(L S -1
c'1
(R)S -2
A--!
Rear
Census Tract
1 Module No.
Initials
16 Architect Firm Name
Street Address
Zip
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 efferent tha 1 above) Ke,�ti C:.Z.
�� mss` pry —C.-.■` .s . _
Business Address
\_- °`` \\ N �..
9 Zip
�. -� i
City
c� p C o`'vr�.
State
v:.i
Phone
(b C z p a_ c \ ---0\
12 Review Required
Plan Check (Y /N)
Other (YIN)
[SEPA Exempt (Y /N)
I Date
15 Type Work R'''.---Bldg
❑ Fire
E MH
n Demo
R' New
❑ Add /Alter
❑ Replace
71 Move
❑ Other
14 Describe Work
K'eSideAre .
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
m,F = 6140 5 P # 71
OS - 54 4I
Pte= eon
a
s �►
El
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
Environmental Health
W. 1101 College
Room 200
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Conditions /Comments•
❑ Commercial; ❑ Residential
❑ New Construction; ❑ Bldg alteration /addition
❑ Additional structure;
APPLICATION #
65-D /7yQ
Planning /Zoning:
N. 721 Jefferson
Conditions /Comments•
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; ❑ lot wld; ❑ lot size; ❑ use /zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ 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 atta
h reasons for hold
Release
Release
w /cond 1
Hold 2
0 /Willi
Planning /Zoning:
N. 721 Jefferson
Conditions /Comments•
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; ❑ lot wld; ❑ lot size; ❑ use /zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ 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 atta
h reasons for hold
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