1985, 05-13 Permit App: 00005392 Reisdence• ,
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BUILDING 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)
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first) (m)
Department Use/Only
1 Owner's Name/') Oast) /
1(`
C / `F 14 '
Fes. ' Comm
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2 Project Address (not Mailing ASpace Zip Address) or Road Name //Q26
3�D I. �e1. ON
3 City/Community
Ct '-'
5'�
1 y6(cx �- /.
Name
I %�i .1. Lo t =1 3 R P an 2)l 77 0A/
(r..
/Y
4 Assessor Parcel N .
V / — (k)el
Lot Q
i/
I Block
* * * DEPARTMENT USE ONLY * * *
,136
5 Slc Code 1
Zone Act. 0
Zone
Project No.SFR 53Q2--
^2--
6 Dwell 0
6
No. of Buildings
Sq. Ft./Acre
I Depth
/25
Frontage
So
7 Set Back -Front
25
(L S-1
. 10
(R)S-2
�D
� Rear
Census Tract
Module No.
Inals
iti
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(91``tCxi
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
Contractor Firm Name
Street
Address
Zipc('2c6
CityState
.3700 u/v r
�V (-t.`'k
Phone
(':(1,) Y-),). '7
Contact Person
License No. „ //.�,,,
D G/�' 6--- -13 ^, 2/C /` 1-
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 (YIN)
Other (YIN)//
SEPA Exempt (Y/N)
Date
15 Type Work l2 Bldg
❑ MH
(i7�/New
❑ Replace
❑ Other
❑ Fire
❑ Demo
❑ Add/Alter
❑ Move
14 Describe Work ,, �n
R 's,c t Aj/� ei C,PJ/@A-R40-cJ
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 Information
PIF = 14620 g -4R =528 ;`'..'`,.
3'F=5►?
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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
Conditions/Comments.
❑ Commercial;
❑ New Construction;
❑ Additional structure;
O Residential
O Bldg alteration/addition
APPLICATION #
1 ti
Planning/Zoning: 0 Commercial; 0 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;
O Other
Conditions/Comments•
Engineers:
N. 811 Jefferson
Conditions/Comments.
O Commercial; ❑ Residential;
O drainage ❑ new access/approach;
❑ road improvements
O Flood Plain;
O 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
Release
Release
w/cond 1
Hold 2
nffk
Planning/Zoning: 0 Commercial; 0 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;
O Other
Conditions/Comments•
Engineers:
N. 811 Jefferson
Conditions/Comments.
O Commercial; ❑ Residential;
O drainage ❑ new access/approach;
❑ road improvements
O Flood Plain;
O 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
1
0
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