1984, 06-08 Permit App: 00000797 ResidenceBUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return th Is original and your building plans to the Department of Building and Safety)
1 Owner's Name (first) (m)
OapeitnimtL e Only
\\(les
crNcNi OW V��ti� C.
R36. 1/
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
F.tt31'2- t4uuA C1 Gckl_c .
3 City/Co'rulnity
o\11-.,a.rD---.
State
W rns\--
Subdivision/Plat Name
s P S3 -..s (v
4 Parcel No. PIN or
a3,5-2-1 a - q r3 -S
Lot Block
Tr (h C� Y\ * * * DEPARTMENT USE ONLY *
5 Sic Code •
K
Zone Act. 1
Zone / Project No. .S �i
el I
6 Dwell 1
X
No. of Buildings1/
g
IZoo'
Sq. Ft./Acre
Depth
Frontage
IR)
7 Set Back -Front s (L)S-1
S
(R)S-2 Rear
1St\7�c
Census Tract
Module No.
Initjay
16 Architect Firm Name I Street Address
Zlp
City
State
Phone
Contact Person
Phone if different than above
( )
Cony\at_or Firm Name (a:1-
'�
�\rR"QM:'N'MW — \CY�\\�CN.--
Street Address p —\
II-\°I°l.l{ 5..3•A-
Zip
C\e\°�V\
City
���1\rt
Stat
(3..S\--....._
Phone
Ig(3°1) 4-)VI-`i6cl
tact Person
...Thr C. Nc.c 'ow
License No.
S - liZ C \SA �
Phone If different than above
( )
8 Owner/Agent of different than N1 above)
Bus) ess Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (V/N)
Its
Oth r (Y/N)
YES
SEPA Exempt (Y/N)
Date
15 Type Work eBldg
0 Fire
0 MH
0 -Demo
V New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
IZC "oe'NCE W/c`
lieuQ'q
10 Applicant Name
Street Address
11 Zip
City
State
Phone
1 )
Lender
Street Address
Zip
City
State
Phone
1 )
Contact Person
Phone if different than above
Additional lnfor tion
1232 Mf
1 boo # GFS .
4404' 4‘e_
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
Environmental Health
W. 1101 College
Room 200
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑l Commercial; f 4esidential
♦,d / New Construction; 0 Bldg alteration/addition
❑ Additional structure;
APPLICATION #
Conditions/Comments
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; /Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage /new access/approach; 0 fence;
O road improvements
Conditions/Comments•
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Rum
tYsv
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 Indkate above or attach reasons for hold
Release
Release
w/cond 1
Hold 2
��
r /'
Conditions/Comments
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; /Residential; 0 Flood Plain;
N.811 Jefferson 0 drainage /new access/approach; 0 fence;
O road improvements
Conditions/Comments•
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Rum
tYsv
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 Indkate above or attach reasons for hold
NTY HEALTH DISTRICT
PV--
3.: €7y
N
f(40. -A- G T I4 t4 6 4 c!,