1985, 05-01 Permit App: 00005202 Addition*
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)
#i.e7411 e/ eY Lee"a
Department Use Only
Res. Comm
2 Project Address (not Mailing Address) a- Road Name Space Zip
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3 City/Community
'
State
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Su Ision/Plat
re
Name
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4 Assessor rcelNo.
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/
Lot
Block
* * * DEPARTMENT USE ONLY * * *
5 Sic Code
Zone Act. S
Zone
2
Project No.
1 6 Dwell #No.
/
of Buildings
/)
Sq. Ft./Acre /,
//t(V
Depth
Frontage
7 Set Back -Front
I (L)S-1
(R)S-2 [Rear
Census Tract
Module No.
Initials
16 Architect Firm Name
Street Address
Zip
City
State
Phone
( )
Contact Person
Phone If different than above
( )
Contractor Firm Name
Street Address
Zip /
Gty_
State
Phone
L�nt son
1 ek
License No.
l4'& 5 /J:2'/
Phone If different than above
( )
8 Owner/Agent (if different than #1 above) �i / X77 f
4
Business Address
9 Zip
City
State
Phone
( )
12 Review Required
Plan Check (Y/N)
Other (Y/N) 1 SEPA Exempt (Y/N)
Date
15 Type Work 17"BIdg
❑ Fire
D MH
❑ Demo
❑ New
d/Alter
❑ Replace
❑ Move
❑ Other
14 Describe Work
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10 Applicant Name
Street Address
11 Zip
City
State
Phone
( 1
Lender
Street Address
Zip
City
State
Phone
( 1
Contact Person
Phone if different than above
( )
Additional Information
1
DEPARTMENT APPROVALS
J ❑❑
Application Type
(Standard unless
otherwise Indicated)
Fast Track
Early Start
•
This is not a Permit
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
Release
Release
w/cond 1
Hold 2
El
Environmental Health ❑ Commercial; ❑ Residential
W. 1101 CollegeA
❑ New Construction; ❑ Bldg alteration/addition
Room 200 ❑ Additional structure;j�
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APPLICATION /r ( lam'
Conditions/Comments:
•
Planning/Zoning: 0 Commercial; 0 Cert. of Exemption; 0 Frontage;
N. 721 Jefferson ❑ Setbacks; 0 lot w/d; 0 lot size; 0 use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
0 Other
Conditions/ Comments•
Engineers: 0 Commercial; 0 Residential; ❑ Flood Plain;
N. 811 Jefferson 0 drainage 0 new access/approach; 0 fence;
0 road improvements
Conditions /Comments
Utilities:
N. 811 Jefferson
Conditions/Comments•
Other:
•
Plan Exam
Fire Prev.
Conditions /Comments:
1 Information ❑1
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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