1985, 04-03 Permit App: 00004757 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 NNaarno (lest) (first) Im)
pgpgnmenllbp Only
�! /C/// 64te / o ie.
✓✓/ Comm
2 Project Address (not Mailing Address) v Road Name Space Zip
/209 it, /Sets, - 992_
3 City/Community
0.6i•re
State
�/y
Subdivision/Plat Name //
_ ' Q /e .S 4'24
I SP
4 Parcel No.
_1
1.4 rj`442 - 280 I
Lot
/
Block
+ * • DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act.#
r
Zone
K Project No.
(2"''..
8 Dwell N
1
No of Buildings
11
q. Ft./Acre
Depth �� '
Frontage
got
7 Set Back -Front
EXl91W4
(L)S-1
(R)S-2 Rear
Census Tract
Module No.
Initials
.ION M
18 Architect Firm Name Street Address
S42/�%
Zip City
State
Phone
( )
Contact Person
Phone if different than above
( )
yI i••
ZfrContractor Flim Nam // / `L [/
Street Address
4" �S�
Zip Clry
992%6 so%EvA�
State
Lv
l
Phne04'
on
Phone
92r-92 Y6
Contact Person
License No.
Phone If different than above
1 )
8 Owner/Agent (If different than 01 above)
Business Address
9 Zip
City
State
Phone
1 )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
SEPA Exempt (YIN)
Date
15 Type Work ( Bldg
0 Fire
❑ MH
0 Demo
❑ New
1g Add/Alter
0 Replace
0 Move
0 Other
1a Describe Work
—
IPan CE fri)D . 560 /�(/ p//
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
1 )
Contact Person
Phone If different than above
Additional Information
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
W. 1101 College
Room 200 •
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
o Bldg alteration/addition
APPLICATION #
Cond'tions/Comme s' •G,'1
PrOW
Planning onin0 Commercial;
Release
Release
w/cond 1
Hold 2
4
U(
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;
N. 811 Jefferson ❑ drainage 0 new access/approach;
0 road improvements
Conditions/Comments.
❑ 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 attach reasons for hold
•
PLUMBING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) (First) (M)
Department Use Only
Project No.
2 Project Address (Not Mailing Address) Space Zip
3 City/Community I State
Subdivision l Plat Name
4 Assessor Parcel No
I Lot
Block
16 Contractor Firm Name
Street Address
17 Zip
City
State
Phone
18 Contact Person
I License No
Phone if different than above
8 Owner/Agent (if different than ill above)
Business Address
9 Zip
City
State
Phone
1 1
15 Describe Work:New 0 ; Addition/Alteration 0 ; Replace/ Repair ❑
Total Number
of Fixtures'
10 Applicant Name
Street Address
11 Zip i
City
State
Phone
9 Bar Sink(s)'
Drinking Fountain(s):
Floor Drain(sl'
Washing Machine(s)'
1
10 tbh Wshr(s)' I
Garb Disp(s):
Kit Sink(s): 1
Lndry Tray(s). I
Sew Elect (s).
11 Urinal(s)'
Wt Closet(s): I
Lav(s): I
Shower(s):
I Tub(s):
I Bidet(s):
Other: Type;
12 Waste/Grease Interceptor(s)
13 Sewer V N Septic/Health No'
14 Electric Water Heater(s):
Drains -Roof
15 REPAIR OR ALTERATION' Drainage, Vent, Water Piping/Treatment: V N
16 Lawn Sprinkler System(s), including backflow device on any one meter:
17 Vacuum breakers or backflow devices In excess of line 16:1-5
(Or) 5+:
I certify that the above information as submitted by me is true and correct and further, agree that all pro-
visions of laws and ordinances governing this type of work, including inspection requirements, will be com-
plied with whether specified herein or not. The granting of a permit does not presume to give authority to
violate or cancel the provisions of any other state of local laws regulating construction or the performance of
construction.
SIGNATURE OF
APPLICATION
OWNER OR AGENT DATE