1985, 09-24 Permit App: 00007655 SidingBUILDING 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 Only
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2 Project Address (not Mailing Address . Road Name Space Zip
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3 Gty/Communit t_
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Subdlvlsion3,yk�t Name
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4 Assessor Parte No.
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Lot
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lock
a • • DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Actt..4
Zone
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Project No. --7h65
6 Dwell I
No. of Buildings
Sq. Ft./Acre
/ 17500
Depth
Frontage
1 Set Back -Front 10.)5-1
(R)S-2 I Rear
Census Tract I Module No.
Initials
16 Architect Firm Name I Street Address
Zip
City
State
Phone
1 )
Contact Person
Phone If different than above
( 1
Contractor Firm Name �v
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Street Address
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Zip l� ?.
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State i
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Phone
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tett Person
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Phone If different than above
( ) ` x�i4 6
8 Owner/Ag nt (if different than M1 love)
Business Address
9 Zlp
City
State
phone
1 )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
I 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 (
K Other
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i1 7. / 4- .97/16e/
14 Describe Work // 1u n2 • �).-1-17.
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10 Applicant Name
Street Address
11 Zip
City
State
Phone
1 )
Lender
Street Address
Zip
City
State
Phone
1 1
Contact Person
Phone if different than above
1 )
Additional information
V l d-/-10 0 y /99 �.0�
1°461°11:P : ii i/ 0, 00 t 1. Clo = 4Ii.50
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Application Type
(Standard unless
otherwise indicated)
Fast Track
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
W. 1101 College
Room 200
❑ Commercial;
❑ New Construction;
O Additional structure;
❑ Residential
❑ Bldg alteration/addition
APPLICATION #
.
Release
Release
w/cond 1
4
Hold 2
Conditions/ Comments• • -
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•
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
0
Other:
0
Plan Exam
Fire Prev.
Cond Itlons /Comments •
Project Representative Telephone
Agencies Performing Special Inspection:
1
2
3.
1 Indicate above or attach conditions relative to llnal as built approval
2 Indicate above or attach reasons for hold