1984, 12-17 Permit App: 00003738 Relocate Garage7O
BUILDING 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) I(� (first / /� (m)
GU.41 P DOMId l_)CIYk
Department Use Only
Res. _Comm
2 Project Address (not Mailing Address) or Road Name Space Zip
it) Hi II ma w\ er ,mA _ 71 a I Cp
3 City/Community
5G4.v. e
State
�/°�
Subdivision/ Plat Name
k]1'�r'> SMO T' O� 230ft D F
4
Parcel No
15 1 1 _ b 708
Lot
Bieck
r . . OEPARTMENTUSEONLY . +
5 Slo Code
Zone Mt. 0
ZoneA6RA
•
Project No
6 Dwell 0
No. of Buildings
S
Sq: Ft./Acre
Depth
23o
Frontage
196
7 Set Back -Front
C•
0.)S-1
—
(R)S-2 Rear
s1 sI
census Tract Module No.
InitialsgXiS-r1I
Jut m'
16 Architect Firm Name , I Street Address
Zip
City
State
Phone
( 1
Contact Person
Phone If different than above
Contractor Firm Name
Street Address
Zip
City
State
Phone
( 1
Contact Person
License No
Phone if different than above
8 Owner/Agent (if different than 01 above)
Business Address
9 Zip
City
State
Phone
I ) 927k
- .9-056
12 Review Required
Plan Check (Y/N)
Other (Y/N)
' SEPA Exempt (Y/N)
Date
15 Type Work 0 Bldg
0 Fire
0 MH
0 Demo
0 New
0 Add/Alter
0 Replace
0 Move
0 Other
14 Describe Wark 46
O�
1- !• V seredb &
l2-4'•Ito
10 Applicant Name
Street Address
11 Zip
City
State
Phone
1 1
Lender
Street Address
Zip
City
State
Phone
1
Contact Person
Phone if different than above
( )
Additional Information
.
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5 UU . .,11-1'—eeafr`.
S/�
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0
k COO - _ •.t-ro .
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;
K. Additional structure;
APPLICATION# 4/5f
❑ Residential
O Bldg alteration/addition
Conditions /Comments•
El
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;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Condltions/Comments
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage 0 new access/approach;
O road improvements
Conditions/Comments
❑ Flood Plain;
❑ fence;
Utilities:
N.811 Jefferson
Conditions/ Comments•
Other:
0
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
Release
Release
wlcond 1
Hold 2
Conditions /Comments•
El
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;
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Condltions/Comments
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage 0 new access/approach;
O road improvements
Conditions/Comments
❑ Flood Plain;
❑ fence;
Utilities:
N.811 Jefferson
Conditions/ Comments•
Other:
0
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
11 o
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