1984, 10-05 Permit App: 00002684 Garage• 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— ---
1 Owner's Na ) (first) (m) Department Use Only
Res. Comm
e h rl D t7 042 re -t-- L� I
2 Project Address (noott Mailing Address) or Road Name Space Zip
C/'
D �d C/Q.21
3 City/Community
®k6/7e_
State
k'�-
Subdiv /Plat Name
�f(.,i(rr(/Are Add
4 —A .,,,,or Parcel No.
may, /__w �53C1_ ^ 1
C iiD
Lot
Block
* 1r* DEPARTMENT USE ONLY it* 1r
5 Sic Code'
Zone Act. #
Zone
SCIe
Project No.
6 Dwell #
i
No. of Buildings
Sq. Ft./Acre
Depth
ld
Frontage
Pi %'
7 Set Back -Front I (L)S-1
(R)S-2 tReaar/ ��
Census Tract
1 Module No.
Initials_
C/ixxef
16 Architect Firm Name I
Street Address
Zip
City
State
Phone
( )
Contact Person
-5-a--%i7.-e—
Phone if different than above
( )
Contractor Firm Name
Street Address
Zip
City
State
1
Phone
( )
Contact Person
License No.
Phone If different than above
( )
8 Owner/Agent (if different than#1 bove) r-^
4
Busir ess Address 328)7/Id
4,4er-1 . e 11 noll
_.......4-3-70fill---r.,
9 Zip
City �, h. .4
State ,
Phone 2-64) 333
33 — 7494 4/
12 Review Required
Plan Check (Y/N)
Other (Y/N) [SEPA Exempt (Y/N)
Date
15 Type Work E<BIdg
9 Fire
D MH
❑ Demo
30/.New
❑ Add/Alter
❑ Replace
0 Move
❑ Other
14 Describe Work
.2'/ X Z'/ C/e Jl e h eC/ Cir€E '7
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
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
❑ Bldg alteration/addition
APPLICATION #
Release
Release
w/cond 1 Hold 2
*
ME
Conditions /Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ 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 Indkate above or attach reasons for hold
;
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