1984, 11-06 Permit App: 00003230 MHw
BUILDING 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 ly
1Departmant
_
(2)011Res. Comm
2 Project Address (not Mali {tddr .) a Road Name Space Zip
/F1102_ • nee
3 ty Communitn / ...
Cil '
State
(//c/�� •
S ivisiun/Plat Nam
d... i t-- / � -C
d�a - iso .2_,Lo,
d
a
Block
* * * DEPARTMENT USE ONLY *
5 Sic Code
Zone Act. If
Zone RN 11
Project No
3.256
6 Dwell f/
No. of Buildings
/
Sq Ft./Acre
Depth
'/026
Frontage
&C
7 Set S&P-Front��
(L S-1
(R) 9 f Rear��
I`�
Census Trect I Module No.
II
Initials
X00 m .
16 Architect Firm Name I Street Address
_Zip
City
State
Phone
( )
Contact Person
Phone If different then above
( )
Firm
NI/tractor Firm Name
Street Address
iisa 4' F.
/� 726
Cit
qpm -1
Ir
State `�
Phone r
.'0Z,?
Cont
son
License No.
4) 7
Phone if different than above
8 Ow /Agent (if different than #1 above)
Business Address
9 Zip
City
State
Phone
1 1
12 Review Required
Plan Check (Y/N)
40
Other (Y/N)
SEPA Exempt (YIN)
Date
15 Type Work jBIdg
❑ Fire
0 MH
0 Demo
0 New
❑ Add/Alter
0 Replace
❑ Move
0 Other
14 Describe6 Work p'
�x ac ___, - -
\_Jac/ /
10 Applicant Name �J
Street Address
11 Zip
City
State
Phone
l 1
Lender
Street Address
Zip
City
State
Phone
1 1
Contact Person
Phone 11 different than above
1 1
Additional information
47
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
J
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
Conditions/Comments-
Planning/Zoning:
onditions/Comments
❑ Commercial;
New Construction;
Additional structure;
APPLICATION# A ID 9i0
❑ Residential
❑ Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
i
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 /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
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
OIL) )l J.
{
/91124
c -_ Oi (AtQS,UJ4 9?027
1 ,
1
j 1
1• ---1- +- �--' j
1 1
•
-+
l
-4
I
r
3
L-
fAfult-
,
i
a
T
r�
—. —; �-- r
i + r
I.