1985, 05-01 Permit App: 00005200 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 Name (last)(first)„ (m)
Department
�r
I e se ,I .LP V Ls
Ras' f/
Comm
2 Project Address (not Mang Address) or Road Name Space Zip
-
5S'10 1 -642 -E ---a A
3 C' Community
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State
UJf43h
Subdivision/Plat N e rR
(Yl Il�� o m e.
4 r Parcel No.
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LotBlock
2
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(
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* * * DEPARTMENT USE ONLY * * Ir
5 Sic Code
Zone Act. #
Zone ,�
3 r
(L
Project No. 2
6 Dwell #
g
No. of Buildings
'
Sq. Ft./Acre
Depth Frontage
7 Set Back -Front
1 (L)S-1
(R)S-2
l Rear
Census Tract
Module No. 9is..e2—).„...„
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
tractor Firm �� C����Street
f'1
` t'74
Address/ �L.5.16..
( ,33
State ��
GatI�Q 1(/ nxJ`�
Phone �JLVV �cJ��
Contact Person
ase No
./
Phone If ddiiffffffeerent th 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)/
SEPA Exempt (YIN)
Date
15 Type Work Bldg
E Fire
❑ MH
❑ Demo
I�" New
❑ Add/Alter
❑ Replace
0 Move
❑ Other
14 Describe Work
-PN 6.-)- tom n> Cg c..0/(j raC ee
10 Applicant Name
Street Address
11 Zip
City
State
Phone
( )
Lender
Street Address I
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
61-1 e OS 33/ 7 S H1 it SS
Mr = /45O 0 4e =&oa
u3= (coo
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 #
Release
Release
w/cond 1
Hold 2
Conditions /Comments
Planning/Zoning: ❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson ❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions /Comments
Engineers: ❑ Commercial;
N. 811 Jefferson ❑ drainage
❑ road improvements
❑idential; ❑ Flood Plain;
new access/approach; ❑ fence;
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/Comments
Other:
Plan Exam
Fire Prev.
Conditions/Comments:
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
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