1985, 03-27 Permit App: 00004553 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 Use ly
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2 Project Address (not Mailing Address) or Road Name Space Zip
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3 City/Community
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State
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Subdivision/Plat
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Name
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4 Assessor Parcel No.
1 2. 03%
Lot 3
Block
* * * DEPARTMENT USE ONLY * * *
3554 •-
5 Sic Code
Zone Act. #
Zone
Project No. '4 S 3
6 Dwell #
No. of Buildings
Sq. Ft./Acre
Depth
Frontage
7 Set Back -Fronto,
3S
I (L S-1
°
(R)S-2
ic-
Rear
3c
Census Tract
Module No.
In Is
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
,
Contractor Firm Name
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Street Address
Zip
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City
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State State
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Phone
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Co tact Person
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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
Other (Y/N)
\
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SEPA Exempt (Y/N)
Date
15 Type Work Bldg
❑ Fire
❑ MH
❑ Demo
New
❑ Add/Alter
El Replace
❑ Move
❑ Other
14 Describe Work
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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
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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
❑ Commercial;
O New Construction;
O Additional structure;
O Residential
O Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
APPLICATION #
Conditions/Comments.
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson 0 Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments.
Engineers: 0 Commercial;
N. 811 Jefferson 0 drainage
O road improvements
Conditions/Comments.
❑
F�!/nnew
ew access/approach;
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
ri.
Conditions/Comments.
To
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ago
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Project Representative
Agencies Performing Special Inspection:
1
Telephone
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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