1984, 07-11 Permit App: 00001113 Relocate Residence• BUILDING 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) 1 9t) (m)
Use Only
• 2- 1-.9 1Lr a L a�t^ol x fh/Cf a KFes.
'Department
1Comm
2 Project Address (not Mailing Address) a Road Name Space //,,
ROD'/7P
+
II
I e.
74l/P
!7'Zip
3 City/Community
J`fim A.•iie_
State
WA-
Subdivision/ Plat Name
5/40/Z PLAT
# 8)4 - 504
4 Assessor Parcel No.
16,542 -p137
Lot
5,
Block
* + • DEPARTMENT
USE ONLY * a'
Sic Code
Zone Acta
Zone
Protect No. I�1
/l
i 'r 1t' 4
6
t
No. of Buildings
7-I5-3'
�. Ft./Acre
thI )
r
110
7 Set Back -Front 1
30
(L S-1 I
1
(R)S-2) I Rear
1
Census Tract
Module No.
lir!,
J
16 Architect Firm Name Street Address
CI 05-515Ec-K — P1c.5 et_ o NZ 6.107-F-6.75 N. 909 nk/Es g
Zip
99 to
Clty
s t7aKANF
Slate
WA.
Phone
(5c )Tta. -975-5 S
Contact Person
p/•=•4l wN/r-TAKF_ rz-
Phone if different than above •
( ) -
Contractor Firm Name�'
/ 0w/j 2
Street Address
Zip rtY
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
12 Review Required
Plan Check (Y/N)
OlhelElc ' SEPA Exempt (Y/N)
\\�,!!// .•--❑�'
Date
15 Type Work Bldg
0 Fire
D MH
0 Demo
New
0 Add/Alter
0 Replace
X Move
0 Other
14 Describe Work ,
rt2,-L0cPA7E EX15T1/-1C, /-I-OVSF T0/4&w I- 07- STo¢a4E 3c»CF
10 A licant Name ./ /
ra't-NI CI a. /k' 42, G✓'c/K
Street Address j� /
4-/07.21./- are adw at
11 Zip
99206
City
5p01<a,-re
State
1A.,A
Phone
(5'a9) 924- 2$ 7'/ .
Lender
Street Address
Zip
'City
State
Phone
Contact Person
Phone if different than above
Additional I nformatipn
A.
1240 (p KtSTIA-CI 9CS) (Ns?ec-zw N SO-, OC) Pato ((2e elm
13G0 -BAsMrr T -v. 8q.00
270 0 sroe Ac g 2.t-t.tt_c p nil. xP- 4 20.00
butt_DIN4 Olooco fcz_-ovin
13-7a4 6 . s,'e ctait
DEPARTMENT APPROVALS -
•
II
.
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
.
1 nls is nota rermit t
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
_
Release
Release
w/cond 1
Hold 2
M
Environmental Health 0 Commercial; 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 0 Additional st-
trructtuure;
APPLICATION N 0 7- 6 7/S
/('—
`- 7 //-;,9)
Condltlons/Comments-
i
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;
IV
.�1��
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comma-Ws-
q.,
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage - 0 0 fence;
ilcit 7
new access/approach;
❑ road improvements
Conditions /Comments'
Utilities:
N. 811 Jefferson
nn
I' yN/4iff
/ 11�� ��--
Conditions/Comments• tatoka P rztAM".'� Q4.
VN�L,�
V-3 oy
Other:
•
Plan Exam -
Fire Prev.
Conditions/Comments
' Information ❑
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
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