1985, 05-16 Permit App: 00005437 GarageAPPLICATION WORKSHEET
BUILDING PERMIT
OF THE FORM OUNDERSTAND
COMPLETE ONLY THOSE PARTS
PLEASE PRINT
AND
of Building and Safety)
(Please return this original and your building plans to the Department
(m) Department Use Only
1 Owner's Name
(first), Comm
(last)
`� Rss'
�w
!/�
PM �.50 v `
Space ZIP 6O
2 Pr ect Address (not Maiiing
Addresa) or Road Name ��
i ktel" 'on/PlatNpme
3
State Subdiv
/G/.t�ylCommunity
Qom` Lot`�
4 Assessor parcel No.
Block LA DEPARTMENT USE ONLY
* * * * *
17 — i
Project No.
Zone
5 Sic Code Zone Act. M %�
�}
No. of Buildings Sq. Ft. lAcre
Depth Frontage
/1 //0
6 Dwell N
`
Module No. Initials
(R)S 2 Rear O3nsus Tract
7 Set Back-Front
(L)S-1 1
*
Street Address
* 16 Architect Firm Name
State Phone
Zip
City
)
Phone if different than above
Contact Person
( )
-L]
Street Address
Contractor Firm Name
City State Phone
)
Zip
Phone if different than above
License No.
)
Contact Person
(
Business Address
S Owner/ Agent (if different than ft above)
City State
Phone
)
9 Zip
(
Plan
Check (YIN) Other (YIN) SEPA
Exempt (YIN)
Date
12 Review Required
Bldg ❑ MH ❑ N w
❑ Replace El Other
15 Type Work
❑ Fire ❑ Demo Add 1 Alter
❑ Move
I
P� j�A P ^ R e,
14 Describe Work
-C37(�J
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Street Address
10 Applicant Name
City
State
Phone
)
11 Zip
(
Street Address
* Lender
State Phone
City )
Zip
(
Phone if different than above
Contact Person
( )
Additional Information
�1,
0
DEPARTMENT APPROVALS
1 Indicate above or attach conditions relative to final as built approval
2 Indicate above or attach reasons for hold
Application Type
1 nis is not a Permit
❑
(Standard unless
otherwise indicated)
Fast Track
(Indicated approvals required in either "release" or "release with conditions"
space prior to permit issuance.)
❑
Early Start
Release
Release w/cond1 Hold 2
Environmental Health
W. 1101 College
-ROQM-200
ElCommercial; ElResidential
❑ New Construction; ❑ Bldg alteration/addition
�9 Additional structures;
Q
APPLICATION #
Conditions/ Comments:
❑
Planning/Zoning:
❑ Commercial; ❑ Cert. of Exemption; ❑ Frontage;
N. 721 Jefferson
❑ Setbacks; ❑ lot w/d; ❑ lot size; ❑ use/zone;
❑ CU, variance, zone change; shoreline; ❑ fence;
❑ Other
Conditions/ Comments:
❑
Engineers:
❑ Commercial; ❑ Residential; ❑ Flood Plain;
N. 811 Jefferson
❑drainage Elnew access/approach; Elfence;
❑ road improvements
Conditions/ Comments:
❑
Utilities:
N. 811 Jefferson
Conditions/ Comments:
❑
Other:
❑
Plan Exam
Fire Prev.
Conditions/ Comments:
Project Representative
Telephone
Agencies Performing Special Inspection:
c
O
1.
E
0
2
c
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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