1984, 07-02 Permit App: 00001008 Pool00
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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) n (first) (m) Department Use Only
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2 Project Address (not Mailing Address) ar Road Name Space Zip
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3 ty/Co munit
r.
State
ubdivision/Plat
Name
4 r Parcel No.
k j
*- 03 14/
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Lot C�
1 I
Block
c3
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. N
Zone
Project No. (jf
6 Dwell iY
1
No. of Buildings
11
Sq. Ft./Acre
Depth ��
Front ^ I
l�Ci
7 Set Backe _ I (L) -1
(R)S-2
'� i 1
I Rjpar
(0 /
Census Tract
I Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact person
Phone If different than above
( )
Contractor FirmName1Name
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Street Address�I
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Cd
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State
(A
>
Phone
(n 9 ) ' -V# s'L7 5
tact3jer sc
No.
License No.
Phone If differ nt than above
8 Owner/Agent (if different than 41 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN)
SEPA Exempt (YIN)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
0 Demo
New
Add/ Alter
0 Replace
0 Move
0 Other
14 Describe Work -S .,r 3/0 (44(_,
10 A nt Name
'NJI.11-1
Street Address
11 Zipty
ate
Phone
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
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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:
0 Commercial;
O New Construction;
O Additional ucture;
APPLICATION #
O Residential
D Bldg alteration/addition
Release
Release
wlcond 1
Hold 2
( j 414ig
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1.111111
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N.721 Jefferson 0 Setbacks; D lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions /Comments
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson El drainage El new access/approach; 0 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 indicate above or attach reasons for hold
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