1985, 03-21 Permit App: 00004613 ResidenceBUILDING PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
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(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
' a�_y G- Lit & . F%s.
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Comm
2 Project Address (not Maili Addr�i) �ord Name`wSpace Zip
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3 CI /Community
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State [9
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u Nisi n/ Plat ams )) n
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4 Parcel No.
(vsva- )0--l0
Lot
(0
Block
i
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act.8
Zone
Project No. �•
--/�
,-
J_
6 Dwell*
1
No. of Buildings
I
Sq. Ft./Acre
Depth
75
Frontage
i38
7 Set Bads -Front`
(L 5- Q
(R)S-2/-
(IC
/
1
Census Tract
Module No.
Initials
16 ArcOjtect•JFiir`/m Name
Street Address A
iirig
Zi
9)- 9-ir
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Stat
-� �— -
Phone
((f fi3) 7 6 0 0
Contact Person_
Phone If different than above
Contractor Firm Name
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Street Address
Zip
City
State
Phone
( )
Contact Person
License No.
Phone If different than above
( )
8ner/Agent(iffdiffifelntthan?1above)
Btu/rsinessAddress /�
7LL a
9 Zip
q q y J L,
C om^---1'
State
;2/4
Phone
( > � 'f - r� C 6 C3
12 Review Required
Plan eck (Y/N)
Other (Y/N)
SEPA Exempt (Y/N)
Date
15 Type Work LI/ 1dg
❑ Fire
❑ MH
0 Demo
C( New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Work
re s , den s c.zi A-rAg
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
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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; ❑ Residential
❑ New Construction; ❑ Bldg alteration/addition
❑ Additional structure;
APPLICATION #
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:
N. 811 Jefferson
Cond' i• s/Comments•
❑ Commercial;
❑ drainage
❑ ro . improvements
❑ Residential;
❑ new access/approach;
-764
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
ore
Project Representative
Agencies Performing Special Inspection:
1
Telephone
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Release
Releeas`e�
w/cond 1
Hold 2
Q
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:
N. 811 Jefferson
Cond' i• s/Comments•
❑ Commercial;
❑ drainage
❑ ro . improvements
❑ Residential;
❑ new access/approach;
-764
❑ Flood Plain;
❑ fence;
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
Plan Exam
Fire Prev.
Conditions/Comments•
ore
Project Representative
Agencies Performing Special Inspection:
1
Telephone
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
1
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