1984, 07-24 Permit App: 00001345 MHBUILDING PERMIT APPLICATION
WORKSHEET EET
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)
Subdivision/ Plat Name
3 City/Community
s
4 Parcel No.
* * * DEPARTMENT USE ONLY * * *
Project No.
Sq. Ft./Acre
Frontage
6 Dwell fl
7 Set Back -Front
16 Architect Firm Name
Zip
G'
Contact Person
Contractor Firm Name
Zip
C
Contact Person
8 Owner/Agent (If different than 01 above)
(L)S-1
(R)S-2
Osnsus Tract
Module No.
Initials
Street Address
Phone
Phone If different than above
Street Address
Phone
Phone if different than above
Business Address
State
12 Review Required
15 Type Work
14 Describe Work
10 Applicant Name
Plan Check (YIN)
Other (YIN)
Phone
SEPA Exempt (YIN)
❑ Bldg
O Fire
❑ New
❑ AddlAlter
O Replace
❑ Move
❑ Other
11 Zip
ender
Zip
Contact Person
Additional Information
Street Address
State
Phone
Phone if different than above
Fast Track/Special Ins
DEPARTMENT APPROVALS
■
•
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
This is nota Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 College ❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;
APPLICATION #
Conditions/Comments•
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; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson ❑ drainage ❑ new access/approach; ❑ fence;
❑ road improvements
Conditions/Comments •
Utilities:
N. 811 Jefferson
Conditions/Comments.
Other:
•
Plan Exam
Fire Prev.
Conditions /Comments •
Project Representative Telephone
IInformation
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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