1985, 04-02 Permit App: 00004734 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)
/74 47%Y0 �, /" • / .
Department Use ly
its. Comm
2 Project Address (not Mailing Address) o- Road Name Space Zip
E.//9/t7 2iv./e.,ra'c
3 City/Community
State
Subdivision/Plat Name
4 r Parcel No.
Oc-16 T/ ` 6-3 ei
T
Lot
Block
2 t r+ DEPARTMENT USE ONLY * *
5 Sic Cade
Zone Act.tf
Zone A�s, /J� Project No.
6 Dwell$No.
/
of Buildings
%
Sq Ft./Acre
Depth
Frontage
>0
7 Set B& -Front
(L5-1
(R)$= 1 Rear
Census Tract
Module No.
Initials
16 Architect Firm Name Street Address
Zip
City
State
Phone
( )
Contac Person
Phone If different than above
Contragtor Firm Name
ci le/t-4(»AtS f , C 4/ J.
Street Address
iu'1.-/ei /11#.Iy`R'e/h rC<
Zip
9 i
City
jpc,�-,A
State
2.614,7
Phone
( ) 9.x6 -70/`z
Contact Person
License No.
C' /Mite A/6. zi'-/1a9/al
Phone If different than above
( )
8 Owner/Agent (if different than 111 above)
Business Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (Y/N)
Other (Y/N) ' SEPA Exempt (YIN)
Date
15 Type Work )= 1idg
0 Fire
0 MH
0 Demo
0 New
,-iii.*•"Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
.25/X.zel . off. Q 4 .p _ : 5710 0:- "
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
DEPARTMENT APPROVALS
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
1 nis 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;
_
.4
•i
��
I
(
�
� t
APPLICATION # / A- / /
Conditions/Comments'
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson ❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
onditions/Comments-0
Conditions/Comments-
0
Engineers: ❑ Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson ❑ drainage 0 new access/approach; 0 fence;
❑ road improvements
Conditions/Comments' '
•
Utilities: . ,
N.811 Jefferson
Conditions/Comments-
•
Other:
•
Plan Exam
Fire Prev.
Cond ltions /Com men is•
' Information ❑
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
4
ADDRESS:
General -
❑ Owne.rship
❑ Applicant
❑ Contractor
O Architect
0 Address
O Legal Description
PROJECT #:
Health
Increased Lot Coverage?
Addition Bedrooms/
Fixtures?
•
Change of Use?
New Septic?
Planni
O Parcel Number Unplatted Property?
Lot Depth: Width > 3:1?
(Less than 10 acres)
Lot Depth: Width > 4:1?
(10 acres plus)
O Zoning Lot Size Less than Minimum?
O Site Plan
Segregation of Platted
Property?
O Plat Map Setbacks Less than Required?
0 Permit Description Frontage less than Required?
❑ Plans Not a Permitted Use in Zone?
❑ Completeness Rezone, Conditional Use,
Variance Involved or Required?
❑ Square Footage Commercial Use or Home
Occupation?
O Occupancy Group 8 Type More than One Residence?
❑ Departmental Releases Adjacent to a Required
and Conditions - Shoreline?
En. ineerin
New Access/Approach?
Private or Unmaintained
County -Road?
Se•a
Underground Tank Over
10,000 Gallons
Commercial Building Over
12,000 Square Feet?
Over'20 Dwelling Units?
Over 40 Parking Spaces?
Agricultural Building Over
20,000 Square Feet?
Landfill or Excavation Over
500 Cubic Yards?
Critical Material
Designated as a Critical
Use Activity?
REVIEWED BY:.
DATE:
Yes No N/A