1985, 07-12 Permit App: 00006374 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 (1 t) (lir 1) Iml
Department .: • ly
y'
•\r
\�I�s//,
1�.Qr
2 ''76 is t Mailing
Project Address jJ�1 ,�{��,,/g
/ v Road /itd,f,u 2 /uc ,r ref N • 7
Dr (%,Comm
V ZVJ 1 OP
3 Clty/Commynity
State
t J
Subdivision /Plat Name
StUfr,v Zuci,�dJ VoI-/Coe, 2
ss�f�
4 r Parcel
3 S 9
No.
3 - 23 os
Lot
5
Block
1
* + • DEPARTMENT USE ONLY * *
5 Sic Code
Zone Act. N
Zone ,Project
11/9
No. 637 /
[(y
6 Dwell a 1
No. of Bulldinps
fl
Sq. Ft./Acre
Depth
1.3.4-6 1
Fron
age
I f o'
Back -Front
7 Set Fro t ) I (L 5-1 f
(R)S-2 I Rear
II
Census Tract I Module No.
Initials
Vpu kl m.
16 Architect Firm Name I Street Address
Zip
City
State
Phone
( 1
Contact Person
Phone If different than above
Contractor Firm Name
76 GU Al s
Street Address
)1 l34 J Ce n 7Lez .
Zip
97 Z-- / z.-
Clty
k—
State
LI
Phone
( )9.2-7-6 7 3'
/}Contact Person
L OrawLG1 w -
License No.
GO/AJ6-6G— z 7-1 .
Phone if different than above
I )
8 Owner/Agent (If different thin' 1 above)
Business Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (Y/N)
Other (YIN)
I SEPA Exempt (Y/N)
Date
15 Type Work � Bldg
Fire
❑ MH
0 Demo
,ie New
❑ Add/Alter
0 Replace
0 .Move
0 Other
14 Describe Work
REST D.Giice (3 - Beds n-,
10 Applicant Name
Street Address
11 Zip
City
State
Phone
`\ Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
s
Additional Information
1294=Mg. 6,24,,a4e
110-- u3
J55 "1.- re
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota 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 4 New Construction; 0 Bldg alteration/addition
Room 200 0 Additional structure;
APPLICATION # 1Juc67/ /
Conditions/CommentsPL(n-_e pt j
p r 77J -r ,e-: 1'6.0,0v
•
Release
Release
w/cond 1
Hold 2
Jimi li=
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone'
0 —CU, variance, zone change; shoreline; ❑ fence;
0 Other
Conditions/Comments:
Engineers: 0 Commercial; 0�,! Residential;
N. 811 Jefferson 0 drainage U,,at new access/approach;
0 road improvements
Conditions/Comments'
❑ Flood Plain;
❑ fence;
,M2Y4 - °EFO
0
Utl Ilties:
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