1985, 04-15 Permit App: 00004947 MH•
BUILDING PERMIT APPLICATION WORKSHEET
PLEASE.PRINTAND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
(Please return this original and your building plans to the Department of Building and Safety)
I 1 Owner's Name (last) (first)- _ (m)
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Department Use Only
Fbs. comm
2 Project Address (not Mailing Address) a Road Name Space Zip
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3 Clty/Community
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State
wA
Subdivision/Plat Name
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4 Assessor Parcel
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No
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Lot
Block
_ ♦ . t DEPARTMENT USE ONLY * *
5 Sic Cade)
Zone Act. 0
Zona .^
Pi
I , Project No.
1�-ITSq.
6 Dwell 0
No. of Buildings
2
Ft./Acre
Depth
l
i
11
Frontage
8 G 1
7 Set Back -Front
3S't
(L S-1 t
s
(R)S-2 j 4-
zr-
Rear
(Onus Tract
Module No.
Initials
JUNW1.
16 Architect Firm Name - - - - I Street Address
Zip
City
State
Phone
1 )
Contact Person
Phone If different than above
( 1
Contractor Firm Name
Street Address
. • 1,','. t "1
Zip
City
State
Phone
Contact Person - -
__ ... _
License No.
- . - - _
Phone If different than above
1 - ) _ "- -
8 Owner/Agent (if different than 01 above)
Business Address
9 Zip
City
State
Phone
1 1
12 Review Required '
Plan Check (Y/N)
Other (Y/N)
SEPA Exempt (YIN)
Date
15 Type Work 0 Bldg
0 Fire
"CMH
0 Demo
0 New
0 Add/Alter
0 Replace
0 Move
❑ Other
14 Describe Work, -
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,t
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10 Applicant Name -
vVN t C ht-Prel-__ 2! 0 -Nit -nibs
Street Address
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11 Zip .
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City
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State
Cu 4
Phone
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Lender
Street Address
Zlp
City
State
Phone
1 )
Contact Person
Phone If different than above
( )
Additional information
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; 0 Residential
,1 New Construction; 0 Bldg alteration/addition
O Additional struct re;/�
APPLICATION # OVJ )"66
/
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.
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Com ments•
El
Engineers: ❑ 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:
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
i
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.
❑ CU, variance, zone change; shoreline; 0 fence;
❑ Other
Conditions/Com ments•
El
Engineers: ❑ 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:
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
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34
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