1984, 05-24 Permit App: 00000365 AdditionBUILDING 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) Use Only
!Department
ki0o BE'L wI3 y /uC L. Res. Comm
1
2 Project Address (not Mailing Address) or Road Name Space Zip
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k.) . aD�a Mar Li er i to \ a
3 Ci /Community �J
`a 1e �
State
W A
Subdivision lPlat Name
M t ch e LU Pik (,2'-l- 4 U-
4 r Parcel No.
ie,75 41'4_-)' 4Z3
Lot
4 -1---
Block
l
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. #
Zone
Project No.
6 Dwell it
l
No. of Buildings
t
Sq. Ft./Acre
Depth r
14-`�
Frontage
'Ct 0 r
7 Set Back -Front
1 (L)S-1
(R)S-2
1 Rear �t
Census Tract
Module No.
16 Architect Firm Name
f Street Address
fl
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
License No.
Phone if different than above
( )
8 Owner/Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other ((YY/N) JSEPA Exempt (Y/N)
r
Date
15 Type Work Bldg
❑ Fire
❑ MH
❑ Demo
❑ New
Add/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
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10 Applicant Name
Gt
A.�/f�
yL�
Street Address
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Iv 2.Q 2-e) 1 t la_AfjUe-�,1
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11 Zip V
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City
. le_w,.t_
State
uuA
- Phone
(bdq) oja - 5c Cr
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone if different than above
( )
Additional Information 1
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 --.Commercial;
W. 1101 College ❑ New Construction;
Room 200 ❑ Additional structure;
sidential
Bldg alteration/addition
APPLICATION ff A i ' (i')
Conditions/Comments
Release
Release
w/cond 1
Hold 2
a�4
S
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;
O CU, variance, zone change; shoreline; 0 fence;
O Other
Conditions/Comments•
Engineers: 0 Commercial; 0 Residential;
N. 811 Jefferson 0 drainage 0 new access/approach;
O road improvements
Conditions/Comments-
0
onditions/Comments
❑ Flood Plain;
0 fence;
Utilities:
N. 811 Jefferson
Conditions / Comments
Other:
c
c ❑
U
N
o
c
Y o
U'-
f6 a6
I- E
L
�y O
V
c
Plan Exam
Fire Prev.
Conditions/Comments
Project Representative
Agencies Performing Special Inspection:
1
Telephone
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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