1985, 02-14 Permit App: 00004185 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 Name (last) (first) (m) Department Use Only
—C -r2 47/1`x] c "2!/1 R3s. Comm
1
2 Project Address (not Mailirtig Address) or Road Name J Space Zip
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3 City/Community
-5-',d 4. ti C1
State
ci $ 4 ‘„
Subdivision/Plat Name
ni / , � c 'Y 7 Qr �' J s/ s c`K .' 7'� , c1
4 Assessor Parcel No.
3 5-5, / v 9 Cl G }
d�
Lot
/
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. 0
Zone
te_ '
Project No.
(�
6 Dwell 0
No. of Buildings
Sq. Ft./Acre
Depth I
13s
Frontage
901
7 Set Back -Front
3S �
(L)S-1
12'
(R)S-2
(2-
t
f Rear
l 4
Census Tract
Module No.
Initials
Jl.\ m .
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Contractor Firm Name
��J2 - - Coo :'1 5 —71 :7::, c,
Street Address
S'' S / ‘,.-1 -al v Li. �• k 1/.) a,
t�Zip i
Clt
State
Phone
Contact Person
License No.
LE k) i :�27p
Phone if different than above
( )
8 Owner/Agent (if different than 01 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N) I
SEPA Exempt (YIN)
Date
15 Type Work E Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work r—J ` 1Ce
10 Applicant Name y ck �/Z
LL /nc. 1
Street Address
- 5 r c 47 0 �a /�
.J �. „e.
11 Zip
/ 2 e E
City
V'0 A 4 ti
State
E'L14 -) 1541,
Phone
(?2C) S •i e G
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
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Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Conditions/ Comments•
Planning/Zoning:
N. 721 Jefferson
Conditions/Comments•
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; El lot w/d; ❑ lot size; 0 use/zone;
O CU, variance, zone change; shoreline; ❑ fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
❑ Commercial; 0 Residential;
O drainage ❑ new access/approach;
O road e GIL�G�f��' �J
❑ Flood Plain;)
O fence;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments'
tec
tff'
.,
Project Representative
Agencies Performing Special Inspection:
1
Telephone
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Release
Release
w/cond 1
Hold 2
APPLICATION #
Conditions/ Comments•
Planning/Zoning:
N. 721 Jefferson
Conditions/Comments•
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
❑ Setbacks; El lot w/d; ❑ lot size; 0 use/zone;
O CU, variance, zone change; shoreline; ❑ fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
❑ Commercial; 0 Residential;
O drainage ❑ new access/approach;
O road e GIL�G�f��' �J
❑ Flood Plain;)
O fence;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments'
tec
tff'
.,
Project Representative
Agencies Performing Special Inspection:
1
Telephone
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
•
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