1984, 05-31 Permit App: 00000444 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 (last) /+ (first) (m)6.
ery.l [ _ Cl•
~�1� `Space
`�
Department lrOnly
Rte. ✓
Comm
2 Project Address (not Mailing �Address)CON �`�� Name A O Zip
5.14315 K
3 Gtylommunity
SP0W.AN
State
WAA
Subdivision/a Name
M t's.1T F S 'f14TTs S 2,11
4 Assessor Parcel No.
Z S s - 0 i 3
Lot
is
Block
3 * * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. 0Zone
Project No. - l
SF tz_
6 Dwell #
I.
No. of Buildings
1
Sq. Ft./Acre
Depth f
i 18
Frontage
toe,
7 Set Balt -Front
�a%
(L)S-1
(Ft)S-2
-
ear
ems ,
Census Tract
Module No.
riti
r is
16 Arch Firm e
�I Ca #4 144 4'iCC
Street Address
i✓ /o,ti Pi NES
Zip 5 gyoe
G Po ksi% NE'
State �J 44
Phone ) g38 -i n1 G
Contact Person
Phone If different than above
( )
Contractor FI Name
! crrt4 AoS ES
Street Address
5.31.4 PiNFS
ZipGty
ci�1b�
_\i
SPO %4A Pe
State 4
Phone
en.e.-4,44g
Contact Person
License No.
OT 174 -pc.*2 3Q')
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 (YIN)SEPA
Exempt (Y/N)
Date
15 Type Work 114dg
❑ Fire
0 MH
❑ Demo
EY/ New
0 Add/Alter
0 Replace
❑ Move
❑ Other
14 Describe Work
Se05 10 w/ 6 At2AGe
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
Am e_ P1./) rV , S S 19, HELENA
.(VL r t 37.-o/61 Soo ' ' YXcLc-
UP (12x16 t 4 uB
6144/- 676-16
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota 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:
❑ Commercial;
❑ New Construction;
Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Release
Release
w/cond 1 Hold 2
1111.111111
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; n lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments:
Utilities:
N. 811 Jefferson
Conditions/Comments:
Other:
a
Plan Exam
Fire Prev.
Conditions/Comments•
APP ver) 74.4A
S ► S (lb «€
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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