1985, 05-09 Permit App: 00005328 Demo GarageBUILDING 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) _
1 / q J / D /
Department ,: • I Y
Fb,.
Comm
2 Project Address (no Mailing Address) or Road Name Space Zip7.
3 City/Community
SA7c/{.,L4
State
`f�i /
Su Ion/Plat Name
flrchord Ave Add
4 Assessor Parcel No.
o 7 gq ,a_ _ 3/. )
Lot
Block
* * * DEPARTMENT USE ONLY
5 Sic Code
Zone Act. 4
Zone h
Protect No. 53�
6 Dwell If
/
No. of Buildings
Z
Sq. Ft./ /Acre
Depth/J'�s(
S
Frontage
�,/�
fa°
7 Set Back -Front I (L S-1
100
(R)S-2 I Rear
Census Tract I Module No.
Initials �
16 Architect Firm Name 1 Street Address
Zip
City
State
Phone
1 1
Contact Person
Phone If different than above
1 1
Contractor Firm Name Street Address
Zip
City
State
Phone
Contact Person
License No.
Phone it different than above
8 Owner/Agent (If different than 41 above)
Busl ess Address
9 Zip
City
State Phone �) Q2'!CJZr/
`l '
12 Review Required
Plan Check (YIN)
Oth r (Y/N)
I SEPA Exempt,(YY/N)
Date
15 Type Work 2' Bldg
0 Fire
0 MH
0 Demo
48" -New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
1(000 97 De1crhed C4traG-e,
10 Applicant Name
Street Address
11 Zip
City
State
Phone
Lender
Street Address
Zip_
City
State
Phone
1
Contact Person
Phone if different than above
Additional Information
DEPARTMENT APPROVALS
s
`c
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
i nis is nota remit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; 0 Residential
W. 1101 College 0 New Construction; 0 Bldg alteration/addition
Room 200 0 Additional structure;
i
APPLICATION #
Conditions/Comments•
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721.Jefferson 0 Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone.
0 CU, variance, zone change; shoreline; 0 fence;
0 Other --
• !
Conditions/Comments
•
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
0 road improvements
Conditions/Comments•
•
Utilities:
N.811 Jefferson
Conditions/Comments.
•
Other:
Plan Exam
•
Fire Prev.
Conditions/Comments.
IInformation ❑I
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indkate above or attach reasons tor hold
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