1985, 03-29 Permit App: 00004664 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)
1s Name (last) (first) (m) Department Use Only
b ,..-e J ; Re. Comm
I
2 Project Address not Ma in - ddress) cr RoaAName Space Zip
v'-SLc).3 c L zt.:✓ kj/c<r tt✓ y 7,,2 et,
3 City/Community
.�.r J
State
_I���
ubdivision/Plat Name
c, �iQi �'�e�� ,
4 Parcel No.
57‘
,' j—'i / / c' c' -2
Lot
11
Block
,t
* * * DEPARTMENT USE ONLY * ,t
5 Sic Code
Zone Act. #
Zone F-11,
Project No.
6 Dwell #
/
No. of Buildings
Sq. Ft./Acre
Depth
(3
Frontage )
gS
7 Set Back -Front •(L
t...3,6//'
S-1
(R)S 2
c
Rear
�S
Census Tract
Module No.
Initials
—1U 3 m .
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street
Address
Zip
CityI
State
Phone
( )
Corr Person
Q4tiy, ..2
License
No.
AEU RI -
2_--7 I3 273c)
Phone If different than above
( )
8 Owner/Agent (if different than #1 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 ❑
0
Bldg
Fire
❑ MH
0 Demo
�, New
0 Add/Alter
❑ Replace
❑ Move
0 Other
14 (Describe Work
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cii411r "..<'-?•[-r,-
10 App 'cant ams
C. .4- f A �c i r F
j/
Street
Address
S c7>;�'V," `"/2 L .c uxJ
11 Z P
99,7e5 6
City
State J
Phone q
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
U 6 = (_CO S 0
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;
❑ Setbacks;
❑ Cert. of Exemption;
0 lot w/d; 0 lot size;
❑ CU, variance, zone change; shoreline;
0 Frontage;
0 use/zone;
❑ fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
❑ Commercial;
O drainage ❑ new access/approach; 0 fence;
O road improvements
❑ Residential; ❑ Flood Plain;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
3 2
Project Representative
Agencies Performing Special Inspection:
1
Telephone
3
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;
❑ Setbacks;
❑ Cert. of Exemption;
0 lot w/d; 0 lot size;
❑ CU, variance, zone change; shoreline;
0 Frontage;
0 use/zone;
❑ fence;
O Other
Engineers:
N. 811 Jefferson
Conditions/Comments.
❑ Commercial;
O drainage ❑ new access/approach; 0 fence;
O road improvements
❑ Residential; ❑ Flood Plain;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
3 2
Project Representative
Agencies Performing Special Inspection:
1
Telephone
3
1 Indicate above or attach conditions relative to final as built approval
2 indicate above or attach reasons for hold
.�1