1985, 04-25 Permit App: 00005114 MHBUILDING 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) Department Only
�%
Ca&w2 v�7cm J Corr ! L /
I
Comm
2 Project Address (not Mali Address) a Road Name Space Zip
I8Y.P I C-- Graft p4: -< S1 - 9re) i6
3 9171Community
TreeN acres
State
Gtv ,
Subdivision/ Plat Name
verv,Pc.v Plot,/ //oHe Sud
4 Assessor Parcel No.
CO n
l�
0755/ - 05°2 -
Lot
2
L-17
Block •
3
•-�
.♦ t DEPARTMENT USE ONLY * *
5 Sic Code
Zone Act. #
Zone
m ti
(
Project No.
5i/
6 Dwell II'
No of Buildings /
Sq. Ft./Acre
/CV
Depth
Frontage
7 Set Back -Front I (L S-1
(R)S-2 I Rear —
Census Tract
Module No.
Initials014 �th
l/9'-
16 Architect Firm Name
I Street Address
I
Zip
City
Slate
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 (YIN) i
I SEPA Exempt (VIN)
Date
15 Type Work 0 Bldg
0 Fire
1V MH
0 Demo
0 New
❑ Add/Alter
C"Replace
0 Move
0 Other
14 Describe Wok /
PelCccreb c%u6/e wide cup/h stwo/awide Mob/ le ddeM&
10 Appli nt 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
t
s
/e3
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health 0 Commercial;
W. 1101 College 0 New Construction;
Room 200 0 Additional structure;
APPLICATION #
Conditions/Comments nuwi
❑ Residential
❑ Bldg alteration/addition
Release
Release' w/cond 1 Hold 2
_
q
ss y �-
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments-
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions/Comments
Utilities:
N.811 Jefferson
Conditions/Com ments•
Other:
Plan Exam
Fire Prev.
Conditions/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
0 i�