1985, 04-18 Permit App: 00005004 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 tr's Name (last) (first) (m) Department Use Only
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I
Comm
2 Project Address (not Mailing Address) a Road Name Space Zip
. 3G 10 I^—o Rz i4 Pa.,' � —
3 Gty/Communi y
State
Subdivision/ Plat Name
4 Assessor Parcel No.
�,3 54-1 _ ,CPC9CaP
Lot
(.4C)
Block
j/ „-
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. 8
Zone
Project No.
6 Dwell N
l
No. of Buildings
1
Sq. Ft./Acre
Depth
j3f '
Frontage
6-1'
7 Set Back -Front
0 I
(L S-1
[ 2 f
(R)S-2
t o `
Rear
Census Tract
Module No.
Initials
J O K ayl
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
cZZ1Z- S1ov.x 0NrcLle..._
Zip pt �
( 20(/ O
City C I
J f aRA
State /
b )n .
Phone /
( ) c7 2-4i-r1a C.
Contact Person
tri) _ C. e)
License No.
Gzev— ‘1 ;41 QKU
Phone If different than above
( ) �,afr.,,.
8 Owner/Agent (if different than 411 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (YIN) I SEPA Exempt (YIN)
Date
15 Type Work ❑ Bldg
E Fire
❑ MH
❑ Demo
❑ New
E Add/Alter
E Replace
❑ Move
❑ Other
14 Describe Work
S (OE Ce.. c,u GPf/LA-a, F.-
10 Applicant Name
Street Address
11 Zip
City
State
'Phone
( )
Lender
IAIA . V uat&. h
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
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Li 1 IvEa
E
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;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
Srw
Release
Release w/cond 1
Hold 2
❑
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
Conditions/Comments:
❑ Residential; ❑ Flood Plain;
❑ new access/approach; ❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments•
Information
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
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
•
4
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(71 4 I) I L.
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