1985, 04-02 Permit App: 00004742 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)I
pepartment IJ Only
Res.
Comm
2 Project Address (not Mailing Address or Road Name .� Space L/ Zip
/
3 City/Community j
"/ i7ji ('ISt-:tv,. r
StateSubdivision/Plat
0,'_. j.
Name
--1 //
I1 1:_i /f'
J
i4% Y1 !/( ,`, 417,-t.',/;77
�
4 Assessor Parcel No.
115S —. 07 09
Lot
9
Block
/
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone IA
Project No. 4 -`JI 4 -26
Dwell #
1
No. of Buildings
k
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Front I (L S-1
(R)S-2 !Rear
Census Tract
Module No.
Initis
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip
City I
State
Phone
( )
Contact Person
License No.
Phone If different than above
( )
8 Owner/Agent (if different th 1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (YIN)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work '�,i[� >
/\�iiilr,(1(? ,�)ir.1/i7 /1i/[-1/ (i,/1/1 i1-1,1)1(', /4,111/:
10 Applicant Name
(‘T/()/— b�+ Ni=�(i2�Ln kc(7.�t
Street Address
_:i', -,,v( - i li)i. ( 1.; 1 )( i .
11 Zip
City
State
Phone ,.
Lender
Street Address
Zip
City
State
Phone
( )
Contact Pers
Phone if different than above
( )
Additional Information
s
W
c
760_
n
co1.1
00
0
L
"0 -
0
LL
DEPARTMENT APPROVALS
r
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application
This is not a Permit
■ast
Type
(Standard unless
otherwise indicated)
Track
4.
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Early Start
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College)0/New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional struucture;
I ,� •,�T'
•
J. Y'~
APPLICATION # �3�0?D-E
Conditions/Comments•
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments•
Engineers:
N. 811 Jefferson ❑ Commercial; ❑ Residential; 0 Flood Plain;
0 drainage 0 new access/approach; 0 fence;
I
0 road improvements
Conditions/Comments •
Utilities:
N. 811 Jefferson
Conditions/ Comments •
•
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
Project Representative Telephone
Agencies Performing Special Inspection:
1
iInformati
2
3
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold