1984, 08-02 Permit App: 00001561 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)
7^ C.V // /CT rvi.L/ L e `e
Department UseQnly
Fes. 1
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
3 City/Community
S/_-7cr /i.-cr G c.-' r-
State
C:U° /fi
Subdivision/ Plat Name
d et f tt O PAIE /Nor?
4 seesor Parcel No.
If) 1542— 4004.
Lot
Block
* * * DEPARTMENT USE ONLY * * *
/ 5 Sic Code
Zone Act. M
Zone
TFC
Project No. .i.,5-(..' I
6 Dwell k
No. of Buildings
Sq. Ft./Acre
Depth I
Frontage
7 Set Bads -From c (L S-1 a
(R)S-2
Rear
Census Tract
Module No.
I als —
16 Architect Firm Name
I Street Address
Zip
City
State
Phone
( )
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 #1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N) I SEPA Lame (Y/N)
lic
Date
15 Type Work Bldg
❑ Fire
❑ MHlir
❑ Demo
New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
1 ,7e -i �,. /!'''e-, /5 -f' TAc-it€o
10 Applicant Name ✓
/12 -f; //1./ L lc •e /
Street Address
/7-i/% �, Cie- « f
11 Zip
% > '? '' �_
City
SA.,:. -7 /('-‘:.",-. w f'
State
/ /4
Phone
(_ .- ) > �/ 5
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
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
❑ Cf9 mmercial; C�Residential
E ew Construction; ❑ Bldg alteration/addition
Additional structure;
APPLICATION #
Release
R; ase /cond 1 Hold 2
'IL 1111
8r -a bit(
Conditions/Comments.
❑
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/Comments:
Engineers: ❑ Commercial; ❑ Residential;
N. 811 Jefferson ❑ drainage ❑ new access/approach;
❑ road improvements
Conditions/ Comments •
❑ Flood Plain;
0 fence;
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
111
Information
Plan Exam
Fire Prev.
Conditions/Comments
Project Representative
Agencies Performing Special Inspection:
1
Telephone
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
/1 0
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