1984, 07-27 Permit App: 00001656 Residenceir
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)
411.
1 Owner's Name ,. (first) (m)
Department Use Only
�(last)
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Ras.
Comm
2 Project Address (not Mailing Address) ar Road Name,/ LL Space Zip
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3 City/Community
_/'L' -- 6,1-57/
State
Subdivision/ Plat Name
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4 Assessor Parcel No.Lot
< 1 0 02_
3 J 1 I —(/ /�,�'rv�C k)�
-7
Block
/
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
5 j-
Project No. 1 r r
6 Dwell #
No. of Buildings
Sq. Ft./Acre
DepthI
Frontage
7 Set Back-Front2-S. I
C S
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(R)S-2 ,
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Census Tract
Module No.
Initials
16 Architect Firrr gyp"J�mmee� /�j %/��
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Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
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Street Address
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Zip >-- 7iCity
State "45,/ /
Phone f ,c_<-7.C----c;
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Cont Person License No.
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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 (YIN)
I SEPA Exempt (Y/N)
Date
15 Type Work Bldg
❑ Fire
D MH
❑ Demo
D New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe
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10 Applic O L% _�,7 //J((,
Stree re�
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11 Zip
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City
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State�.
Phone9?
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Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( 1
Additional Information
�% _ 2.),L 6' S {-)- J U t_ 2 °71984
r7� = 2- L = 5 ECEIVE--
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
A
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 #
Release
Release
wlcond 1
Hold 2
Conditions/ Comments •
❑:
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; ❑ lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
0 Other
Conditions/Comments•
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage 0 new access/approach;
0 road improvements
Conditions/Comments •
❑ Flood Plain;
❑ fence;
O
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
W
Plan Exam
Fire Prev.
Conditions /Comments:
XYAL
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
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