1985, 04-20 Permit App: 00005201 Residence•
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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)
1 Owner's Name (last) (first) (m) Department Use ly
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2 Project Address (not Mailing Address) ar Road ams Space
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3 City/Community
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Subdivision/Plat Name
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4 Assessor Parcel No.
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Lot
/
Block
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* * * DEPARTMENT USE ONLY ,t ,t ,t
el 5 Sic Code
Zone Act. #
Zone 1 `
Project No.
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6 Dwell k
1
No. of Buildings
1
Sq. Ft./Acre
Depth
135'
Frontage
gS' .
7 Set Bads -Front
(L)S-1
(R)S-2
Rear
Census Tract
Module No.
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16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
CoeStractor Firm Name
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reet Address
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Zip
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City
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State
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Phone
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Contact
Contact Person
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License No.
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Phone if different than above
( )
8 Owner/Agent (if different than M1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
c j 1 1k4,A ,..G., Fire
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❑ Demo
et New
❑ Add/Alter
❑ Replace
0 Move
0 Other
14 Describe Work
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10 Applicant
ne
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Street Address ss
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11 ZipCity
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State
Phone6
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Lender �jki Street Address
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Zip
City
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StatePhonePo
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Contact Per n
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Phone If different than above
( )
Additional Information 7
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. II
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1
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DEPARTMENT APPROVALS
d
•
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
•
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION #
Conditions/Comments. �`''''
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson 0 Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments•
�8
II
Engineers:111/47
En ineers: ❑ Commercial; ❑ R idential; ❑ Flood Plain;
N. 811 Jefferson CIdrainage Nnew CIfence;
d
access/approach;
❑ road improvements
Conditions/Comments. /Nib e72 17
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
•
Plan Exam
Fire Prey.
Conditions /Comments:
Information ❑I
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3
1 indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold