1985, 05-15 Permit App: 00005417 Garage- pgjsz- I46�.
BUILDING 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 Own@r' Name (last) (first) (m)
'C L J/'etY
Department Use Only
Res. Comm
2 Project Address (not Mailing Address) or Road Nade Space Zip
Toe Z
3 tylCommunity
State
L ' ,
Subdivision/ Plat Name
LOAC,H i�t sr s
4 Assessor Parcel No.
Q
Lot
Block
DEPARTMENT USE ONLY * 1r tr
5 Sic Code
Zone Act. M
Zone i
Project No. 11
,1
6 Dwell #
p C
No. of Buildings
� �✓f
Sq. Ft./ Acre
Depth
20
Frontage
9-7,
7 Set Baric -Front
x6 /
(L)S-1
(R)S-2
Rear
Census Tract
Module No.
Initials
JAN
16 Architect Firm Name
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 p1 above)
Business Address
9 Zip
City
State
Phone
12 Review Required
Plan Check (Y N)
Other (YIN) SEPA
Exempt (YIN)
Date
15 Type Work f� Bldg
❑ Fire
❑ MH
El Demo
C$ New
ElAdd/Alter
- Replace
F Move
C Other
14 Describe Work
10 Applicant Name
Street Address
11 Zip
City =ate
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person I
Phone if different than above
Additional Information
4
tll
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application Type
This is not a Permit
❑
(Standard unless
otherwise indicated)
Fast Track
(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
W. 1101 College
Room 200,
❑ Commercial; ❑ Residential
❑ New Construction; ❑ Bldg alteration /addition —1�
❑ Additional structure;
APPLICATION #
Conditions/ Comments:
Ibl
❑
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; ❑ Flood Plain;
N. 811 Jefferson
❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/ Comments:
❑
Utilities:
N. 811 Jefferson
Conditions/ Comments:
❑
Other:
❑
Plan Exam
Fire Prev.
Conditions/ Comments:
Project Representative
Telephone
Agencies Performing Special Inspection:
C
O
1.
m
E
`o
2
c
3.
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
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