1986, 03-06 Permit App: 00009906 ResidenceBUILDING 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�me (last) (first) (m)
1oepartmenpCnIy
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.. L e , ( ;c /%__ , . Res. ��
(2:9-0-(2-)b�/F�
Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
74 c/ o .3c__ .,41).f.�� 99 2 0 6'
3 City/Community
State
Subdivision I Plat Name
4 Assessor Parcel No. vatAi.�i �/
, 3.3i/_1_24-e-
-�, y=' 7"
Lot
QO2/
Block
* ,t ,t DEPARTMENT USE ONLY * * ,t
5 Sic Code
Zone Act. k
Zone ��
Project No.
Web
6 Dwell 8
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back-Fr/o�nt
1 (L S-1
ici
(R)S-2
,
1 Rear
Census Tract
Module No.
Initials
9/X1f)
16 Architect m Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor rm Namele �� ��j
r �/
S X07 »( J
Zip
9� o
City
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State
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Phone
G-5-09) 9V-,5-,..31.0 o
ContacttPP `son
CSS �l
License No.
1-2- ELA kz 4-aa7ZIY-
Phone if different than above
( )
8 Owner/Agent (i different than 81 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN) SEPA Exempt (Y/N)
1
Date
15 Type Work Bldg
❑ Fire
❑ MH
❑ Demo
g New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe rk
II
10 Applicant N-6:1-e"--;-742"4-16-'z
amevv, ffU
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
576 attr2
DEPARTMENT APPROVALS
•
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
this is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION #
Conditions/Comments.
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
0 CU, variance, zone change; shoreline; ❑ fence;
0 Other
Conditions/Comments•
•
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; ❑ fence;
lap,
❑ road improvements
Conditions/Comments• (/ — 0 2 / 7 ...a)
c
2 /7
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Et/'
Plan Exam
2^i5—g5
Fire Prev.
Conditions/Comments.
IInformation ❑ 1
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
•
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