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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 ,,_„,,),..„,„_,;,..„.., 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