1984, 06-11 Permit App: 00000626 Detached 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)
4k-_ l (.Z�.acs Vk J
(first)
k -AC—G`
(m)
Department Yee Only
Fes. Comm
2
Project Address (not Mailing Address) or Road Name Space
Ziip}
3
City/Community State
DT(S 4ti'cNA S
Subdivision/ Plat Name
C'b+��N -LITS
LFSTi4T�s
4
Assessor Parcel No.
LotI
Block
`
* * * DEPARTMENT USE ONLY
5
Sic Code
Zone Act. M
Zone NNAA Project
No.
6
Dwell M
No. off Buildings
Sq. Ft./ Acre
Depth
Frontage
7
Set Back -Front (L)S-1
2Z1
(R)S-2
Rear
Census Tract
Module No.
"a
16
Architect Firm Name
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
ractor Firm Name
>�1;7(<- CE
StrrAddress
k b$
Zip ^
city
State
Phone
) 65" —! 7
Contact Person
License No.
Phone if different than above
8
Owner/ Agent (if different than Mt above)
Business Address
9
Zip
City
State
Phone
12
Review Required
Plan C eck (Y/ N)
5
Other (YIN) SEPA
t�S
Exempt (Y/N)
Date
15
Type Work Bldg
ElFire
❑ MHNew
F1Demo
❑ Add/Alter
ElReplace
❑ Move
❑ Other
14
Describe Work
10
Applicant Name
Street Address
11
Zip
City
State
Phone
Lender
Street Address
Zip
City
State
Phone
Contact Person
Phone if different than above
Additional Information
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
IN
1 nls Is not a Hermit
Application Type
❑
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑
Early Start
I Release
le w/cond 1
Hold 2
Environmental Health
El Commercial; Residential
W. 1101 College
❑ Construction; ❑ Bldg alteration/addition
Room 200
_,Xew
12' Additional structure;
Co ions/Comments:C
APPLICATION #
e.
❑'
Planning/Zoning:
❑ Commercial; El 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:
N. 811 Jefferson
❑ Commercial; Residential; ❑ Flood Plain;
❑ drainage ❑ new access /approach; Elfence;
Conditions/ Comments:
❑ road improvements
u
E1"
\ G�
❑
Utilities:
N. 811 Jefferson
!I
Conditions/ Comments:
❑
Other:
❑
Plan Exam
Fire Prev.
Conditions/ Comments:
Project Representative
Telephone
Agencies Performing Special Inspection:
C
1.
0
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
IN
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