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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 siy /477/ r.or ':5-;'< /;