1985, 04-04 Permit App: 00004708 ResidenceBUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
/9/b
(Please return this original and your building plans to the Department of Building and Safety)
1 Owner's Nam ,// •)(la�st)�,/ /(fi'r'st) (m)
/�eY L17Y���'r C2 �`fly� U/� .
Department Use Only
Res.
Comm
2 Project Address (not Mailing Addre cr Road Name Space Zip
3 CitylCommun pO/�
State Y)
�U
Subdivision/ret L <�/ / o c ,
4 Assessor Parcel No.
j 7 0 3
j
35 f 3 -
Lot 2
._ J
Block
3
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zonet Act./ #
Zone `��
Project No. 7 0c
6 Dwell#
No. of Buildings
Sq. Ft./Acre
Depth�� i ,
Frontage )
7 Set Back -Front (L S-1 f
30 ` 12(,?
(R)S-2
iDt
Rear
l _
(knsus Tract
Module No.
_
Initials
Sot rn .
16 Architect Firm Name
5�,._R_____
Street Address
I - -- 60 6 3i -c,/ .
Zip
99Za
City
� %��4—R____
State
te),,4
Phone
(. 6i ) 7Y7-77 a7
Contact Person
e L . (,?CSS
�/
Phone If different than above
( )
Contractor Firm Name
�tK--S1
Street Address
Zip
City
State
Phone
( )
Contact Person
,�,4AJ12
License No.
C I Z4/4
Phoneif different than above
( )
8 Owner/Agent (if different than #1 above) �y� 52---
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN) 1 SEPA Exempt (Y/N)
Date
15 Type Work 0 Bldg
❑ Fire
0 MH
0 Demo
,' New
❑ Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work ` /ez f ij „ /
10 Applicant Name
S
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
�pAdditional Information C r t
f l 1 092 ia Ki i / 1 rE fp � i .., ,M_'+? �;"•
1
2 BCtJ-fI(C, ,I
111
V ",. s 7 o 11
DEPARTMENT APPROVALS
•
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1 nis is not a Fermat
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
{�
/•
Environmental Health ❑ Commercial; 0 Residential
W. 1101 College 0 New Construction; ❑ Bldg alteration/addition
Room 200 0 Additional structure;
-3/2 7_/`f.s-
coo ' `
r-14//---
-7
APPLICATION # (1 -/ l 9
f / . /
Conditions/Comments. ,'AL1_ ., -.As, /%li.a...d .00
—� /
❑
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;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments.
�
Engineers: 0 Commercial; ❑ Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
3
0 road improvements
Conditions/Comments•FA 2,0
❑
Utilities:
N. 811 Jefferson
Conditions/Comments -
Other:
14.
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative Telephone
c
0
Agencies Performing Special Inspection:
1
76
Eti
2
c
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
4.1
---
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3 /
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