1984, 03-30 Permit App: 84A-2770 AdditionBUILDING 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)
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Department Use Only
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Comm
2 Project Address (not Mailing Address) cr RoadNameSpace Zip
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3 City/Community
G* e—
State
/
Subdivision/Plat Name
4 Parcel No.
A ssaes& a
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✓
'/ — J
Lot
Lot
Block
. * , DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No.
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front
(L)S-1
(R)S-2
I Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
Street Address
Zip
City
I State
Phone
( )
Contact Person
License No.
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 (YIN)
Other (YIN)
SEPA Exempt (Y/N)
Date
15 Type Work p'' Bldg
0 Fire
❑ MHyaw
0 Demo
❑
Add/Alter
❑ Replace
0 Move
❑ Other
14 Describe Work
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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
Application Type
(Standard unless
otherwise indicated)
rst Track
rly 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
Co ditio s/Comments -.16, _
•
artMii'.�IT_ Yr,
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
Bldg alteration /addition
APPLICATION # 3-30-
Co
-3Q-
Release
Release w/cond 1
Hold 2
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; D Frontage;
❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments.
�'i ..�. ,
N. 721 Jefferson
Engineers: ❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ 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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