1985, 04-15 Permit App: 00005010 Relocate Residence/yw
1.3, '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 Name (last) (first)/ lm) \
®periment I. Only
Gu �%14i� �f:/%h 0
IE. ✓ Comm
2 Project Address (not Mailing Address) cr Road Name • • Space Zip
1r. i l2O S FREaeta\c_ic ' get ZO6
3 City/Community
.5 46-ei4/JP
State
WASf(,
Subdivision/Plat Name
Ryes est cf
4 Ae9mwr Parcel No.
OCIS%Z". rJe't
eN
Lot
/
Block
/
* * * DEPARTMENT USE ONLY * * *
5 Sic Cade
Zone Act. a
Zoned..
FIZ
Project No.
6 Dwell N
1 _. .
No. of Buildings
_ , .
Sq. Ft./Acre
Depth
Ilc+' 1
Frontage
U3
7 Set Beck -Front (L S-1
•
(R)S-2 I Rear
Census Tract I Module No.
I
G7-
16 Architect Firm Name' I Street Address
Zip
City
State
Phone
l 1
Co Person
Phone If different than above
Contractor Firm Name
Street Address
Zip
City ,
I State
Phone
( 1
Con Person
License No.
Phone If different than above
)
8 Owner/Agent (11 different than 111 above)
Business Address
9 Zip
City
State
Phone
( 1
12 Review Required
Plan Check (Y/N)
/`)CS
Other (VIN) ' SEPA Exempt (Y/N)
IC}
Date
15 Type Work 1d Bldg
0 Fire
❑ MH
0 Demo
❑ New
.0 Add/Alter
❑ , Replace
r Move
0 Other
14 Describe Work >
10 Applicant Name
Aax t-accc_
Street Address
C Q e (1 Yrr cr i t
11 Zip
44zoC..
City
State -
Phone
( ) gzG,- / SC,/
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone 11 different than above a 3/ it
Co
Additional Information L'A4ts' - Ill •
moue o flzarn ?WC' - d7 54 t - - levo 1 - r -
C, h'1oC T2. vT. .131'.
-$ 68-
.sTVmhTr"0 Coil 03 r -0010/411,0N = Y S-100 = 5.1. = Sb . `=
11 6 °"
f
Application Type
(Standard unless
otherwise indicated)
Fast Track
/arly Start
Environmental Health
W. 1101 College
Room 200
Conditions / Comments•
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
O ommercial; /Residential
New Construction; O Bldg alteration/addition
❑ Additional structure;
APPLICATION # ' 1 --(79/
Release
Release
w/cond 1
Hold 2
nil, tt
Planning/Zoning:
N. 721 Jefferson
❑ Commercial; 0 Cert. of Exemption; 0 Frontage;
❑ Setbacks; ❑ lotw/d; ❑ lot size; ❑use/zone.
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/ Comments.
Engineers:
N.811 Jefferson
Conditions/Comments
❑ Commercial;
❑ drainage
❑ road improvements
pdsidential; 0 Flood Plain;
new access/approach; 0 fence;
Utilities:
N. 811 Jefferson
Conditions /Comments'
Other:
ci,
(91
C�
N
d
n
h c
s
0
E
y
as
LL
Plan Exam
Fire Prev.
Conditions/Comments-
Project
onditions/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
a- c4
hi1 I"h s,
Ag I' or II
Us
0
'7.