1985, 02-15 Permit App: 00004182 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 N e (I (first) (m)
Department Use Only
�Q/ 1� /_ l
* �'�
f3s. Comm
2 o)ect Address (not Mailin Address) or Name Space Zip
34%07 �. �r
3 City/Commup(Zy
.`CD
State
Subdfvl ' Plat amg _97 / �{ J /
e/ (JOh'�SZ Q/ �T`'iC1T/q�yL
4 Assessor Parce�.
LotBlock
/0
1 1
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone ��
Project No.
L
II
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
x36,` 4
Frontage `
SS
7 Set Back -Front
3o'
(L 8-1
26 t
(R)S-2
2(T"
Rear
Census Tract
Module No.
Initials
.! 0 (\
16 Architect Firm Name S ,R
I Street Address / O 6 2 �ci •
Zip ���6 y
City �,��
Stateii.);4_,
Phone(
,) 2 V2 - 7 7 3 7
Contact Person _
Phone70( If different ho
thanye� _ n
Contractor Firm Name
‘"
Street Address
Zip
City
State
Phone
( )
Contact Person
License No.
,�--/UP C I / .21/74
PhoneIf different than above
( )
8 Owner/Agent (if different than #1 above)C "—\
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Workf. Bldg
❑ Fire
E MH
❑ Demo
Yl. New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work / C Cl e 9*leV � — / • at
\
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 lnformation /
P F = 8 72 {9'I
ZF = -
U6 _ 1 7 PI
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;
E Additional structure;
❑ Residential
❑ Bldg alteration/addition
101
Release
Release
w/cond 1
Hold 2
APPLICATION #
Conditions/Comments.
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; ❑ lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Comments.
Engineers: ❑ Commercial;
N.811 Jefferson 0 drainage
❑ road improvements
Conditions/Comments.
❑ Residential;
O new access/approach;
/W4 -n3 /
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/ Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
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
10� goe.k ./ , AI( 4-)-71,(L_
3
co' 'L