1985, 07-03 Permit App: 00006223 GarageBUILDING 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 Bul!di ng and Safety)
1 ner's Name ) (first) (m)
papartment Only
^�y1 %I /((la�stt))
j C C. l'!I ppe I/ I( i I
�. Comm
2 Pro)ect Atldress(no2Maliy gAtltlreag)c+tl 4LnhQd Space Zip
,i/ lyo^(p V[/\/V
3 CItyy/jrComm'unityy
n((a!Lt..
State
Vit=
Subdivision/Plat
4-
Name
wmo OW -9 • l//PooP5(flr7
4 Assesso Parcel No.
Lot
Block
O^ 5-12 - '7 201'
+ ♦ + DEPARTMENT USE ONLY * * *
5 Sic Cade
Zone Act. p
Zone r"d'I V
I Protect No. eo` n 3
6 Dwell ftI
No. of Buildings
3
Sq. Ft./Acre
Depth
0 I
Frontage )
5-t-
7
Set Back -Front
.171NG
(L)S-11
3
(R)S-2 j Rear 1
- D
Census Tract I Module No.
Initials
als
JO
' 16 Architect Firm Name I Street Address
Zip
City
State
Phone
1
Contact Person
Phone If different than above
( )
Contractor Firm Name,,,Street
Gtp, / (If i)77 C�itr5
Address
/cF4' Leto
Z
il
Gty
ltd
—dgi
State
1,P
Phone
(S9) 4<344 2/
Contact Person�/�
J'(1P Y / to 72iC
License No.
OI C/FC r9v�I LZ
Phone If different than above
( )
8 Owner/Agent (if different than p1 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 ,� BIdg
0 Fire
0 MH
❑ Demo
New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
DErA-CffEo not. (2)113o)10
Applicant Name
Street Address
11 Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone If different than above
( 1
Additional Information
DEPARTMENT APPROVALS
•
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1 nis is nota rermlt
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; 0 Residential
W.
W. 1101 College 0 New Construction; 0 Bldg alteration/addnitiory�.,J
Room 200 0 Additional crura; ^/>(
F.� 1
S ,
LOU
�,( /
7--
—a�
1;
z , D !
APPLI
Conditions/Comments• - � • " IP i 4tj kl ui/b{a.e_LA
�
%f
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.
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments
❑
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson ❑ drainage ❑ new ❑ fence;
access/approach;
❑ road improvements
Conditions / Com ments.
0
Utilities:
N. 811 Jefferson
Conditions/Com ments•
•
Other:
•
Plan Exam
Fire Prev.
Conditions/Comments.
iInformation ❑
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indkate above or attach reasons for hold
911,iu Ec•
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