1984, 06-29 Permit App: 00000948 ResidenceBUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSEPARTSOF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Name (lest) (first) (m)
Department Use Only
/� �J
5 wah (Yro ry a Jf o
1439. Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
At 5-1/69 OM £s/ Al 99214
3 Clty/Community
S�o/C/2Nr
Stale
Cr../9
Subdivision/Plat Name / / I
_ Stall C)e3 First" ,4Jd
4 Parcel No.
35./fe 3 — /Era 5—/
Lot
S
Black
r f ♦ DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. II
Zone Project No.
Sr- r-. cote)
6 Dwell If
I
No. of Buildings
1
Sq. Ft./Acre
Depth
1
Frontage
I
I�T
7 Set Back -Front (L S-1
�Zt I %r I
( )S-2 j Rear
( I —
Census Tract Module No.
I
Initial
-ION m.
wi
16 Architect Firm Name I Street Address
Zip
City
Stale
Phone
( )
Contact Pelson
Phone if different than above
( )
Contractor Firm Name
09Cal-r Stan
Street
IVa
Address p.f /
S SIV fle nn co gJ
Zip //
�/‘
City��
S,oKan50'
State
(U<2.
Phone
(fel 9) ?2t'-(o3Sy
Contact Person
License No.
SWAN" �reis0I
s
Phoneif different than above
( )
8 Owner/Agent (If different than 41 above)
Susi
ess Address -
9 Zip
City
State
Phone
12 Review Required
Plan Check (Y/N)
Other (YIN)
I SEPA Exempt
(Y/N)
Date
15 Type Work 0 Bldg
0 Fire
❑ MH
0 Demo
' New
0 Add/Alter
0 Replace
0 Move
0 Other
10 Describe Work 5
10 Applicant Name
Sar.'7e a5 A -icy -C.
/
Street
Address
11 Zip
City
State
Phone
( 1
Lender
Street Address
Zip
City
Stale
Phone
Contact Person
Phone if different than above
Additional Intlrma,lOn IN
W
e ^ (19).
it '
(7$. urs
O
El
LJ
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 0 Commercial; 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 0 Additional structure;
APPLICATION# gL --"6 7V.0 — 9/ Y
Conditions/Comments- 7(preA
L22&1241/ tab. �� siA.Afrt-
Release
Release
w/cond 1
Hold 2
1.g,1
El
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot wld; ❑ lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments'
o'
Vay
Engineers: 0 Commercial; f�7 Residential; Flood Plain;
N.811 Jefferson ❑ drainage Zl new access/approach; 0 fence;
O road improvements
Conditions /Comments•
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
/
334
c
33
fl' HEARM DISTRICT
tv-
37'o 1Sza/
4
AD Bed Room
5 rn?4r P„,mdy Rer,
10 6-