1984, 10-19 Permit App: 00002943 Garage, PatioBUILDING 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)
/ /p .(last) first) •/(m)
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Department Use Only
R3s.
Comm
2 o(ect Address (not Mailing Address) a Road Na a Space Q Zip
/l718' 29/a ,.... 4,2. r....„-...„ .t.
3 City/Community
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4 Assessor Parcel No.
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,/5
Lot
4
Block
I
♦ • : DEPARTMENT USE ONLY * * *
5 Sic Cod/ a
Zone Act. If
Zone rn
I ,
Protect No. ^
r
6 Dwell* I
No. of Buildings
Sq. Ft./Acreth
SIFrontage
1 I
7 Set Back -Front
2St
(L)S-1
--.
(R)S-2 'Rea—
Census Tract
Module No
�tla7ls m 1\1 -
UU
16 Architect Firm Name_- - - - - — - - _ - I Street Address
, f
Zip — - — -
_ . _-
City -
State
Phone .
1 1
Contact Person - , — - — _
Phone If different than above
1 )
Contractor Firm Name — --
Street Address
Zip -
City
State
Phone
Contact Person
License No
Phone if different than above
( )
i 8 Owner/Agent (If different than et above)
Busi ess Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N)
I SEPA Exempt (Y/N)
Date
15 Type Work ❑ Bldg
0Fire
❑ MH
0 Demo
0 New
0 Add/Alter
0 Replace
0Move
0 Other
1
14 Describe Work '4)t 6b /7/4/E 11 K10.PA ` 0
10 Applicant Name
Street Address
11 Zip
City
State
Ph
7(22 5 / g-ir
Lender
Street Address
Zip
City
State
Phone
( )
Contact Person \
Phone if different than above
Additional Information
Application Type
(Standard unless
otherwise indicated)
Fast Track
Early Start
Environmental Health
W. 1101 College
Room 200
DEPARTMENT APPROVALS
This is nota Permit
(Indicated approvals required in either 'release' or "release with conditions"
space prior to permit issuance.)
❑ Commercial;
❑ New Construction;
❑ Additional structure;
❑ Residential
❑ Bldg alteration/addition
Release
Release
w/cond 1
Hold 2
20 (ifi
APPLICATION #
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/Comments
Engineers: 0 Commercial; 0 Residential; 0 Flood Plain;
N. 811 Jefferson 0 drainage ❑ new access/approach; 0 fence;
O road improvements
Conditions/Comments
Utilities:
N. 811 Jefferson
Conditions/Comments'
0
Other:
0
Plan Exam
Fire Prev.
Conditions /Comments•
Protect 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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