1984, 10-01 Permit App: 00002577 Hay ShedBUILDING PERMIT APPLICATION WORKSHEET
' PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return thls original and your building plans to the Department of Building and Safety)
1 Owner's Name (last) 1 Department Use Only
j—� /�,ry,r �n[ ,,//��// �(first) /�(m)
C V/Oi"✓ Kell/M4ni /v/ Lfbs. Comm
2 Project Address (not Mailing Address) or Road me Space Zlp
Soar/1 /201
3 City/Community
UCA/1-0;teS779
State
Subdivision/ Plat Name
/doltFoob 4C C5 Y
Assessor Parcel No.
4 2.454 3 - 05 23
Lot
Z
3
lock
I
r + : DEPARTMENT USE ONLY * *
5 Sic Code
Zone Act. 5
Zone
Project No.
6 Dwell flNo.
L
of Buildings
2-
Sq. Ft./Acre
Depth
3 30.43
Frontage
I gi -80'
7 Set Back-Front(L)S-1
Z1491iNG 1
(R)S-2 Rear
lz` I -
Census Tract
Module No
Initials
Jur.) M
16 Architect Firm Name I Street Address
Zip
City
State
Phone .
1 )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip
City _
State
Phone
Contact Person
License No.
Phone If different than above
8 Owner/Agent (If different than 51 above)
Business Address
9 Zip
City
State
Phone .
12 Review Required
Plan Check (YM)
Other (Y/N)
I SEPA Exempt (Y/N)
Date
15 Type Work IS Bldg
' 0 Fire
0 MH
0 Demo
0 New
0 Add/Atter
❑ Replace
0 Move
0 Other
14 Describe Work '
HPSY 51-feir
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City -
State
Phone
( )
Contact Person
Phone if different than above
( 1
Additional information
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
s
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
❑ Commercial;
❑ New Construction;
❑ Additional structure;
APPLICATION
O Residential
O Bldg alteration/addition
Release
Release w/cond 1
Hold 2
FIK.
Conditions /Comments•
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions /Comments•
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
❑ road Improvements
Conditions / Comments •
Utilities:
N. 811 Jefferson
Conditions/ Comments'
0
Other:
0
Plan Exam
Fire Prev.
Conditions / Comments•
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 Indkate above or attach conditions relative to final as built approval
2 Indkate above or attach reasons for hold
si.