1985, 09-04 Permit App: 00007408 Residence+
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 None (last) (first) (m)
Department U/qa Only
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2 Project Address (not Mailing Address) cr Road Name Space Zip
6 1-6177 t -D21 r-
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3 City/Community
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State
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Subdivision/Plat Name
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4 Assessor Parcel No.
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Lot
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Block
.1
+ + + DEPARTMENT USE ONLY * * *
5 Sic Oude
Zone Act. #
Zone 7� /�
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Project No.
4 6 Datil 0
1
No of Buildings
)
Sq. Ft./Acre
Depth
Frontage
9
7 Set Back -Front
(145-1
(R)S-2
Rear
Census Tract
Module No.
Initials
16 Architect Fkm NameI Street Address
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Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor F Name
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Street Address
N s flr4//17
Zip
Cl/20 4
City
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State
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Phone
92c- 76 C3 .
Contact Person
C� rcL 4 /L7Ast (
License No.
F/Ac/16/2 2S/ tar
Phone If different than above •
. (- )
8 Owner/Agent (if different than 01 above)
Bus ess Address
9 Zip
City
State
Phone
12 Review Required
Pla Check (Y/NIOther
(Y/N)
SEPA Exempt (YIN)
Date
15 Type Work Bldg
0 Fire
0 MH
0 Demo
-New
❑AAdd/Alter
0 Replace
0 Move
0 Other
14 Describe Works h7 J , ---sem le,& /C4
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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
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DEPARTMENT APPROVALS
❑
❑
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1 Ills is nota rermit
(Indicated approvals required In either "release" or "release with conditions"
space prior to permit issuance.)
, •
Release
Release
w/cond 1
_ Hold 2
Environmental Health 0 Commercial; 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 0 Additional structure;
•
• '"APPLICATION if - - t•
Conditions/Comments
❑
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;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments•
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•
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage 0 new 0 fence;
/
access/approach;
0 road Improvements
Conditions/Comments ' • tWA-.3rPS (--
❑
Utilities:
N. 811 Jefferson
Conditions/ Comments-
Other:
I
Plan Exam
?1 _s
,
Fire Prev.
. L i
i/".
Conditions/Comments
IInformation 0
Protect Representative Telephone
Agencies Performing Special Inspection:
1
2
3 - -
1 Indicate above or attach condltlons relative to final as built approval
2 Indicate above or attach reasons for hold
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