1985, 03-25 Permit App: 00004656 ResidenceBUILDING PERMIT APPLICATION WORKSHEET
390
A 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)
00
1 Owner's Na {j aa'',, t) , / / (first (m)
jLolre..7� -- cFC'L5Y-l7 _TGDYL.
Department Use Only
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2 Project Address (not Mailing Adtria\ss) or Road Name Space Zip
3 City/Community / -
/—
State
��
Subdi ion/Plat Name D
3c/25fee�� '"1\10 <
4 Assessor Parcel No.
'3.'f� —1505
j50 5
Lot
5
Block
1 /
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone ���
Project No. — f / (�
�J
6 Dwell #
1
No. of Buildings
Sq. Ft./Acre
Depth
191 +
Frontage
Ifo
7 Set Backront ( 1
(L S-1 L r
col
(R)S-2
Rear (
Census Tract
Module No.
Initials
�VIA-
16 Architect Firm Name
S -`--e_—
Street Address I
.!)& .3rd.
Zip
�gz�y
City
M-70629/Ca--y(-Q--
State
6)4
Phone
Phone
7e/7 —77 a7
Contact Person
`6&=._ W/S
Phone If different than above
( ) 5a-9-._
Contractor Firm Name
5ce----7-+(52—
Street Address
Zip
City I State
1
Phone
( )
Contact Person
License No.
.,1-N�i2C..1/ 5F__ A-
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)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
0 Fire
❑ MH
0 Demo
X New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work � � ^ / ^/
SC d CJ Cc C, fI _
10 Applicant Name
S—(2._
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
Additional Information W 5
F. e•
L& 0I i
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if
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• ^3,1
R1
TMENT APPAPPROVALS
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1 nis is nota rermit i.
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
cg
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 ❑ Additional structure;
Sc��.7.�/-? t, -Q..
Itis
APPLICATION # ( 5-&/ 7f
Conditions/Comments.7/1-77/7g/gt‘74-1478
TPlanning/Zoning:
0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; ❑ fence;
0 Other
Conditions/ Comments•
VEngineers:
❑ Commercial; 0 Residential; 0 Flood Plain•
N. 811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
❑ road improvements
Conditions/Comments• /*I`Y m2
Utilities:
N. 811 Jefferson
Conditions / Com ments-
•
Other:
n
0
Plan Exam
/3,2,7,r
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 Indicate above or attach reasons for hold
673
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