1984, 04-18 Permit App: 84A-3508 GarageBUILDING 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 Only
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2 Projec Address (not Mai ng4-0---4a
ress) or Road Name Space Zip
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3 GtylCommur5i
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State
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Subdivision/Plat
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Name all
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4 Assessor Par o.
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Lot
Block
�r �r + DEPARTMENT USE ONLY * * *
5 Sic Code
Zone ct. #
Zone
Project No.
6 Dwell#
No. of Buildings
Sq. Ft./Acre
Depth ,
Frontage
7 Set Back -Front I, t9(
..C(1(R)S-2
1 (L S-1
1 Rear t
'v
Census Tract
I Module No.
In —
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Con�[aFtor Firm Name
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Street Address
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Zip
ate
Phone'LSt,xt ( )G "V3 V
Person :
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License No.
Phone if different than above
( )
8 % er/Agent Of differ th #1 above)
Busir ess Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Qpec N)
\\iill//����
Othe (Y/N)
c�
t SEPA Exempt (Y/N)
1
Date
15 Type Work ifl- Bldg
❑ Fire
❑ MH
❑ Demo
New
❑ Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describ Work./ 7.a,
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10 Applicant Name Q�� �/�
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Street Address
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(Phone
11 Zip
City
State
Lender
L.
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information
Application Type
(Standard unless
otherwise indicated)
❑ast Track
yF Early Start
DEPARTMENT APPROVALS
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Environmental Health ❑ Commercial; Residential
W. 1101 College ❑ ew Construction; ❑ Bldg alteration/addition
Room 200 Additional structure;
APPLICATION # ®d
Conditions/Comments.
Release
Release
w/cond 1
Hold 2
...----
4/—, p -may
Planning/Zoning: ❑ Commercial; ❑ 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; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
O road improvements
Conditions/Comments.
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
Plan Exam
Fire Prev.
Conditions/Comments.
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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