1985, 05-03 Permit App: 00005248 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 (last) (first) (m)
■■
Department Only
' C. �.. .) .
FIs. ✓ Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
S. 1905 Gorr kI;n
3 City/Community
I< C+...�
State
\�
Subu lvislonn//Plat Name (/�� _/- / L
`\ 1 cA .Q..y+ti O N' 0 1d ' 11r 01y
4
?C 5—
`Code
Lot
12
tock
* * * DEPARTMENT USE ONLY * *
5 Sic
Zane Act. N
Zone Pro) ect No. ^2
5F
6 Dwell M
No. of Buildings
/
Sq. Ft./Acre
Depth
/ 7F
Frontage
i{ 6'
7 Set Back -Front
301�=...1.
(L S-1 (R)S-2 Rear
—"
Census Tract
Module No.
Initials
G/Yt)
*
16 Architect Firm Name
s; S,� �.,, c.�..
Street Address
N. 1 D i y r *.,cs
Zip
951-0 c'
City
ktr
State
w
Phone
( ) 92p• -%o1 4
Contact Pe(ren 1
'Qtr.". \ �i"�Y
f
1'C h T
Phone If different than above
( )
Contractor Firm Name
+I-,
t s
Streetdress
.. 1-2- (g. Pt .s 2cj
Zip
City
State
Phone
Contact Person
G a v k7 C2i,4.
License No.
d 4 c 2-o GL,C)
Phone If different than above
( )
8 Owner/ Agent (if different than 01 above)
I Business
Address
9 Zip
City State
Phone
{ )
12 Review Required
Plan
Check N
Other (Y/N)
SEPA Exempt (YIN)
Date
15 Type Work
❑
Bldg
Fire
❑MH'�lew
❑ Demo
❑ Add/Alter
❑ Replace
D Move
❑ Other
14 Descrite Work
Pe,s cif -Alec,
w AP 4
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address V r
ZIp
f City
State
Phone
( 1
Contact Person
Phone if different than above
( )
Additional Info ation
%Gt AI 15 66S iC, PM rid ,- S 16 3 (4� b1f - PSS) (�D t fp
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 ❑ Commercial;
W. 1101 College ❑ New Construction;
Room 200 0 Additional structure;
Conditions/Comments•
APPLICATION #
O Residential
O Bldg alteration/addition
�� 0
A #
Release
Release
w/cond 1
Hot" 2
MEM
Aix,
.j
Planning/Zoning: ❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot wld; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments•
Engineers:
N.811 Jefferson
Conditions/Comments•
O Commercial;
O drainage
O road improvements
❑ Residential;
❑ new access/approach;
,/✓4 1Y3
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments
0.
C
Y
0
Es co
E
E
u_ —
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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ley
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