1985, 09-04 Permit App: 00007236 AdditionBUILDING 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)
:1 -- V/� I ire (. `
Department Only T1234.
Rss. Comm —
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2 Project Address (not Mailing Address) a Road Name Space Zip
A/ / aa,v4/ eg R-0, y'f e,9 /C,
3 City/Community
S � 5-ki e
State
ti -ba.
Subdivision/Plat Name
4 Assessor reel No.
l liSt13 ���7
Lot
Block
SIM11111111.01SION
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. if
Zone
t A GS�
Project No.
6 Dwell M
/
No. of Buildings
2-
Sq. Ft./Acre
Depth
/50
Frontage
/28
7 Set Back -Front
(L S-1
r 5
(R)S-2 Rear
I
census Tract
Module No
Initials
J
lad
c"
16 Architect F Name I Street Address
5—a. Ai)
Zip
City
State
Phone
l 1
Contact Person
Phone If different than above
( 1
Contractor Firm Name
Sa 4eC-
Street Address
Zip
City
State
Phone
Contact Person
License No.
Phone If different than above
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( 1
12 Review Required
Plan Check (Y/N)
Other (Y/N) I SEPA Exempt (YIN)
Date
15 Type Work Bldg
0 Fire
❑ MH
0 Demo
0 New
&I/Cid/Alter
0 Replace
0 Move
0 Other
14 Describe Work
kLs/oENCE Aoorrion,E[/oY3V-) 110X28)
10 Applicant Name
Street Address
11 Zip "-
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
1 1
Contact Person
Phone if different than above
( )
Additional Information
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DEPARTMENT APPROVALS
]
]
Application Type
(Standard unless
otherwise indicated)
Fast Track
` Early Start
11110 10 111J1. Cl rat II PIP.
-
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release w/cond 1 1
Hold 2
r
Environmental Health
W. 1101 College
Room 200
Conditions/Comments'
l 1 Commercial; ❑ Residential
i1 New Construction; E Bldg alteration /addition
N
aj
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1( /
❑ Additional strucre;
APPLICATION # ((QQ"��cc
❑
Planning/Zoning:
N. 721 Jefferson
Condltions /Comments:
❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
lot 0 lot size; 0 use/zone;
0 Setbacks; 0 w/d;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
❑
Engineers:
N. 811 Jefferson
Conditions/Comments•
0 Commercial; ❑ Residential; 0 Flood Plain;
0 drainage 0 new access/approach; 0 fence;
0 road improvements
❑
Utilities:
N. 811 Jefferson
Conditions/Comments:
Other:
• Y
Plan Exam
Fire Prev.
Conditions/Comments.
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iff
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Project Representative
Agencies Performing Special
1.
Telephone
Inspection:
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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