1985, 06-28 Permit App: 00006220 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 t) (first) (m) f Department lie Only
G . 3 f Fes. - Comm
2 Project Address (not Mailing Address) cr Road Name Space Zip
'.5 '-t-22.s--- 13 a z.4) eic 5Y CZ_ ,:i0 /9z6-6
3 City/Community /�
bKCIL, A -a-
ate
-6I
Subdivision/
- O
Plat Name � ,J
rSt 73 7 1 C,4d tJ-
4 Assessor Parcel No.
35 � --/�o�
Lot
'7
Block
3
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
ZoneSF 2
Project No.
67,22-
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth i
/6
Frontage
glo
7 Set Back -Front I (L 1S
35
(R)S-2
L
_
l Rear
Census Tract
Module No.
Initials�
�'
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name/
vf& trk- ,....11 o`-, 5L/ �T� >~s TVG.,TVG.,`
Street
Address
6. ct X 6 �/
Zip
1 �' .96 3 7
City
V &rim �
State
I (.1_./6i,_
Phone
(.5-6`f) gz-'e-rs lz,
Contact Person
•14A -k—
License No.
CO kb-s-r_I'" 16. Ls"
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 (YIN)
Other (Y/N)
SEPA Exempt
(YIN)
Date
15 Type Work [Bldg
0 Fire
❑ MH
❑ Demo
1=4"'"New
❑ Add/Alter
E Replace
❑ Move
❑ Other
14 Describe Work
(S/ONCE C,e)/aARAC-
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
.fo53=N65, —= LW 2
7g 57& QA('is L. _.
.'
372=F&
El
El
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
Conditions/Comments.
O Commercial; Residential
D New Construction; 0 Bldg alteration/addition
EJ Additional structure;
Release
Release
w /cond 1 Hold 2
MEM
APPLICATION #
X7&
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;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments:
Engineers: 0 Commercial;
N.811 Jefferson 0 drainage
O road improvements
Conditions/ Comments•
5esidential;
IP"new access/approach;
/WA Or7
O Flood Plain;
O fence;
171
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
ADDRESS: S V225 @c(4/()iS 1/ r"'1 PROJECT #:
General - Yes No N/A
l? wnership Health
❑ Applicant Increased Lot Coverage?
Fd'Contractor Addition Bedrooms/ ;.,/r
Fixtures?
❑ Architect Change of Use?
New Septic?
• Address
g' -
Legal Description Plannin
I2/5arcel Number Unplatted Property?
Lot Depth: Width > 3:1?
(Less than 10 acres)
Lot Depth: Width > 4:1?
(10 acres plus)
ffZoning Lot Size Less than Minimum?
fd i to Plan Segregation of Platted
Property ?
❑ Plat Map Setbacks Less than Required?
• Permmit Description Frontage less than Required?
C'Plans Not a Permitted Use in Zone?
♦f Completeness Rezone, Conditional Use,
Variance Involved or Required?
❑ Square Footage Commercial Use or Home
Occupation?
❑ Occupancy Group & Type More than One Residence?
D Departmental Releases Adjacent to a Required
and Conditions - Shoreline?
En•1neerin
New Access/Approach?
Private or Unmaintained
County -Road?
Sepa
Underground Tank Over
10,000 Gallons
Commercial Building Over
12,000 Square Feet?
Over 20 Dwelling Units?
Over 40 Parking Spaces?
Agricultural Building Over
20,000 Square Feet?
Landfill or Excavation Over
500 Cubic Yards?
Critical Material
Designated as a Critical
Use Activity?
REVIEWED BY:.
QAVO DATE: 67-28-65
0'
PV6
# 9-463
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